RCif^l 


intiieCttpoflirtjigDrk 

College  of  $i)p£(ician£(  anb  ^urgeonsi 
Hibrarp 


KK'hLUC.'-ICH:  p.  GAY,  M.  D. 

UNIVERSITY  OF  CALIFORNIA, 

BRRKJSI.'GY,   CAL,. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicalcomplicat1909hare 


THE  MKDICAI;  COMI'liKJATIOXS 
A(J(J1I)EKTS  AM)  SI':(^|;ELS 


OF 


TYPHOID    FEVER 


OTHER  EXANTHEMATA 


BY 

HOBART  AMORY  HARE,  M.D.,  B.Sc. 

PROFESSOR     OF      THERAPEUTICS       IN      THE      JEFFERSON'      MEDICAL      COLLEGE      OF     PHILADELPHIA 

PHYSICIAN    TO  THE    JEFFERSON  COLLEGE    HOSPITAL;    ONE    TIME  CLINICAL  PROFESSOR 

OF     DISEASES    OF     CHILDREN     IN     THE     UNIVERSITY    OF     PENNSYLVANIA 

AND 

E.  J.  G.  BEARDSLEY,  M.D.,  L.R.C.P.  (Lond.) 

ASSISTANT     PHYSICIAN     TO    THE    OUT-PATIENT     DEPARTMENT    OF    THE     JEFFERSON     MEDICAL 

COLLEGE      hospital;      ASSISTANT     DEMONSTRATOR     OF     PHYSICAL     DIAGNOSIS 

AND  CLINICAL    MEDICINE  AT  THE    JEFFERSON    MEDICAL  COLLEGE 

PHYSICIAN     TO     THE     HENRY     PHIPPS     INSTITUTE 


WITH  A  SPECIAL   CHAPTER    ON   THE 

MENTAL  DISTURBANCES  FOLLOWING  TYPHOID  FEVER 

BY 

F.  X.  DERCUM,  M.D. 

professor    OF   MENTAL   AND    NERVOUS    DISEASES   IN   THE   JEFFERSON    MEDICAL    COLLEGE 


WITH   26   ILLUSTRATIONS  AND  2    PLATES 


LEA  ifc  FEBIGER 

PHILADELPHIA    AXD    XEW   YORK 


Entered   according  to  Act  of  Congress,  in  the  year  1909,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


THIS 

ESSAY  IS 
DEDICATED 


W.  W.   KEEN,  M.D.,  LL.D. 


EMERITUS  PROFESSOR  OF  THE  PRINCIPLES  OF  SURGERY  AND  OF  CLINICAL  SURGERY 


JEFFERSON    MEDICAL    COLLEGE    OF    PHILADELPHIA 


PREFACE   TO   SECOND  EDITION. 


At  the  })r('soiit  time  there  are  few  diseases  so  widespread  as 
typhoid  fever,  and  the  Hterature  concerning  it  is  very  great. 
Systems  of  medicine  and  text-books  innumerable  deal  with  its 
ordinary  manifestations,  and  touch,  necessarily  but  briefly,  upon 
its  accidents,  its  complications,  and  its  secjuels.  Anyone  who 
has  had  even  a  limited  experience  with  typhoid  fever  has  met 
with  cases  in  which  the  manifestations  wandered  so  far  from  the 
classical  descriptions  of  the  disease  as  to  be  puzzling  and  obscure, 
or  with  instances  in  which  the  malady  has  been  so  altered  in  its 
course  by  intercurrent  affections  as  to  be  unusual  and  to  call  forth 
all  the  diagnostic  knowledge  and  therapeutic  skill  of  the  physician. 
The  following  pages  deal  with  these  aberrant  forms  of  the  dis- 
ease and  the  courses  wdiich  they  pursue. 

The  preceding  paragraph,  taken  from  the  preface  of  the  first 
edition  of  this  book,  gives  in  a  concise  form  the  reason  for  the 
appearance  of  the  present  volume.  During  the  ten  years  which 
have  elapsed  since  the  first  edition  appeared  the  literature  dealing 
with  typhoid  fever  has  greatly  increased,  and  the  advances  which 
have  been  made  in  the  study  of  the  disease  by  bacteriological 
methods  have  added  to  our  knowledge  of  many  of  its  complica- 
tions and  sequels.  The  present  time,  therefore,  seemed  auspicious 
to  bring  the  text  of  the  first  edition  up  to  date,  and  this  has  been 
accomplished  with  the  assistance  of  the  junior  author. 

During  the  last  decade  much  interest  has  also  been  taken  in  the 
complications  and  sequels  of  the  exanthema  tons  fevers  other  than 
typhoid,  and  for  this  reason  chapters  dealing  with  these  phases  of 
variola,  scarlet  fever,  measles,  chickenpox,  and  rubella  have  been 
carefully  prepared  and  added  to  the  original  text. 

So  far  as  we  know^,  no  other  book  is  devoted  solely  to  this  im- 
portant part  of  medical  practice,  and  the  authors  hope  that  a 


vi  PREFACE  TO  SECOND  EDIT  10 X 

presentation  of  the  literature  as  it  exists  today,  combined  witli  a 
statement  of  their  own  experience  in  hospital  and  private  practice, 
will  prove  useful  to  other  members  of  the  medical  profession. 

As  mental  disorders  not  rarely  ToIIdw,  anil  sometimes  com- 
plicate, ty})hoid  fever,  Dr.  F.  X.  Dercum,  Professor  of  Mental  and 
Nervous  Diseases  in  the  Jefferson  Medical  College,  has  added  an 
interesting  and  instructive  chapter  on  these  states,  for  which  we 
wish  to  express  our  cordial  tlianks. 

H.  A.  H. 

E.  J.  G.  B. 

Philadelphia,  September,  1909. 


CONTENTS. 


PAKT    I. 

THE   MEDICAL   COMPTJCATIOXS  AND   SEQUELS   OF 
TYniOlD  Oil  ENTERIC  FEVER. 

CHAPTER  T. 
General  Considerations 1  ~ 

CHAPTER  II. 

Varieties  of  Onset 41 

CHAPTER  III. 

The    Aberrant    Symptoms,    States,     or    Complications     of     the 

Well-developed  Stage  of  the  Disease 68 

CHAPTER  IV. 
The  Complications  of  the  Period  of  Convalescence 182 

CHAPTER  V. 
The  Conditions  which  Resemble  Typhoid  Fever 266 

CILAPTER  VI. 
Duration  and  Immunity  to  Second  Attacks 276 

CHAPTER  VII. 
The  Mental  Complications 282 


viii  COXTEXTS 

PAET    II. 

COMPLICATIONS  AND  SEQUELS  OF  THE  ERUPTIVE 
FEVERS  OTHER  THAN  TYPHOID  FEVER. 

CHAPTER  I. 

^■AHIOLA 301 

CHAPTER  II. 
Scarlet  Fever 317 

CHAPTER  III. 
Measles 348 

CHAPTER  IV. 
Varicella  (Chickexpox) 373 

CHAPTER  V. 
Rubella       .      .    '  . 384 


PAii^i^  J. 

THE  MEDKAL  (X)MIMJ(JATI()NS  AND  SEQCELS 
OF  TVIMIOII)  on   ExNTEIlIC  FEVER. 


CHAPTER    I. 

GENERAL  CONSIDERATIONS. 

It  may  be  said  by  those  who  are  disposed  to  \)e  critical,  that 
an  essay  deahng  with  the  mecHcal  compHcations  and  sequels  of 
typhoid  fever  must  of  necessity  deal  with  the  disease  in  so  wide 
and  general  a  manner  as  to  include  practically  all  that  we  know 
concerning  it;  but,  while  this  is  to  a  certain  extent  true,  on  the  other 
hand,  it  is  manifest  that  the  important  subjects  of  etiology  and 
pathology  will  not  find  space  for  their  consideration,  and  that  the 
simple  unaltered  forms  of  the  malady  will  only  have  to  be  described 
sufficiently  to  indicate  the  real  variations.  No  one  who  has  had 
any  experience  with  this  disease  can  fail  to  have  noted  that  it  pre- 
sents widely  different  symptoms  in  degree  and  in  kind,  not  only  in 
different  epidemics,  but  in  different  individuals,  and  in  the  same 
individual  at  different  periods  of  a  single  attack.  In  some  patients 
the  illness  is  so  mild  as  to  be  only  a  moderate  indisposition ;  in  others 
so  malignant  that  death  speedily  ensues;  and  yet  in  nearly  all  cases 
there  are  certain  manifestations  which  when  grouped  together 
render  it  possible  to  make  a  diagnosis  fairly  certain.  A  febrile 
course,  characterized  by  malaise,  headache,  fever,  drowsiness, 
intestinal  disorder,  enlargement  of  the  spleen  and  liver,  the  erup- 
tion of  rose  spots,  the  positive  blood  culture,  and  the  confirmatory 
Widal  test,  may  be  considered  to  represent  true  uncomplicated 
typhoid  fever;  and  with  cases  presenting  these  general  symptoms 
this  essay  wall  not  deal.  On  the  other  hand,  the  object  in  view 
is  to  discuss  three  classes  of  the  manifestations  of  t^'phoid  infection, 
2 


18  GENERAL  CO.XSIDERATJOXS 

namely;  (a)  those  ordinarv  syinptoins  of  onset  and  complete  devel- 
opment which,  bv  reason  of  nuxK'ration  or  modilication  or  exag- 
geration, become  interestino-  or  dangerous  in  themselves;  (6)  those 
which  are  so  rarely  met  with  during  onset  or  the  course  of  the  malady 
in  ordinary  cases  that  they  can  be  considered  as  distinctly  complica- 
ting conditions;  and  (c)  those  results  of  the  disease  which,  coming 
on  after  it  is  about  to  cease  in  itself,  still  retard  or  interfere  with  the 
rajnd  and  normal  return  of  the  patient  to  perfect  health. 

We  are  well  awaie  that  at  certain  })oints  it  will  seem  that  the 
dividing  line  between  the  ordinary  symjitoms  and  those  considered 
in  these  pages  is  overstepped,  antl  while  it  is  not  our  intention  to 
avoid  this  overstepping  when  the  complete  discussion  of  the  condi- 
tion is  necessary  to  a  thorough  study  of  the  process  under  considera- 
tion, these  ordinary  symptoms  will  not,  as  a  rule,  be  fully  considered. 

Diminution  of  Morbidity  and  Mortality. — Before  proceeding 
to  a  clinical  study  of  the  disease,  it  is  interesting  to  note  that  its 
/  severity  and  mortality  are  distinctly  on  the  wane.  While  isolated 
epidemics  may  range  in  severity  from  mild  to  severe,  and  produce 
a  mortality  from  less  than  1  per  cent,  to  almost  50  per  cent.,  the 
average  being  at  one  time  about  25  per  cent.,  the  general  mortality 
is  now  much  less  than  this,  often  only  10  per  cent.,  and  in  private 
houses  where  the  family  is  well  enough  placed  to  give  the  patient 
every  aid,  it  is  often  less  than  5  per  cent.,  even  when  the  treatment 
instituted  is  not  all  that  could  be  desired. 
I  These  changes  have  been  produced  by  improved  sanitation,  a 
natural  modification  in  the  severity  of  the  infection,  coupled,  per- 
haps, with  an  increased  resistance  on  the  part  of  the  individual, 
and  by  better  treatment,  and,  as  they  bear  an  interesting  relation  to 
other  modifications  of  the  malady,  may  be  discussed  at  this  point 
with  propriety. 

In  regard  to  the  effect  of  improved  sanitation  it  can  be  pointed 
out  that  Mosny  has  shown  that  the  death-rate  of  Vienna  decreased 
from  12.05  per  10,000  to  1 .1  after  a  pure  water  supply.  In  Dantzic 
the  mortality  fell  from  10  per  10,000  to  2.4,  and  finally  to  1.5  per 
10,000.  In  Stockholm  it  fell  from  5.1  in  1877  to  1.7  in  1887.  So, 
too,  in  Boston  from  17.4  in  1846-49  to  1.05  in  1907.  The  follow- 
ing table  is  of  interest  in  this  connection: 


DIMINUTION 

o/<'  Moim/urr)' 

AXh   \inirr. 

1 /./'/■ 

y       I!) 

Mortality  in  Miinkii 

(•'IIOM 

1S.",1     i<-    1'.K17 

I'lT     100,(1(11) 

IVr  100,000 

Year. 

liiliahil.antti. 

Annual 

.   iiilialiil'iHH. 

'>'car. 

InliabilantH.  A 

iiiiiial. 

inli.-il.it'iil". 

1851, 

123,<)57 

123 

!!!).() 

1880, 

223,700 

100 

72.0 

1852, 

125,588 

152 

121.0 

1881, 

230,028 

11 

18.(i 

1853, 

127,219 

2,35 

181.0 

IH82. 

2.30,400 

\2 

18.0 

1854, 

128,850 

293 

227.0 

IH83, 

242,800 

■\r, 

19,0 

1855, 

130,481 

253 

193.0 

1884, 

249,200 

34 

1  1,0 

185G, 

132,1.12 

384 

291.0 

1885, 

255,600 

45 

18.0 

1857, 

133,847 

390 

291.0 

1886, 

202,000 

55 

21.0 

1858, 

135,733 

453 

334.0 

1887, 

208,400 

28 

10.0 

1859, 

137,005 

240 

175.0 

1888,' 

292,800 

31 

10.5 

1860, 

140,624 

163 

109.0 

1889, 

300,000 

31 

10.1 

1861, 

144,334 

172 

119.0 

1890, 

331,000 

28 

8.5 

1862, 

148,200 

300 

202.0 

1891, 

357,000 

24 

0.4 

1863, 

154,602 

'  252 

163.0 

1892, 

372,000 

11 

3.0 

1804, 

160,828 

397 

247.0 

1,S93, 

385,00(1 

.57 

14.8 

1865, 

167,054 

338 

202.0 

1894, 

39:'.,000 

10 

2.5 

1866, 

168,265 

342 

203.0 

1805. 

400,(100 

1.", 

2.5 

1867, 

169,476 

88 

52.0 

1896, 

412,000 

14 

3.4 

1868, 

170,688 

136 

80.0 

1897, 

4.30,000 

23 

5.0 

1869, 

170,000 

190 

111.0 

1898, 

446,000 

14 

3.0 

1870, 

170,000 

254 

149.0 

1899, 

460,000 

15 

3.0 

1871, 

170,000 

220 

129.0 

1900, 

490,000 

28 

6.0 

1872, 

169,693 

407 

240.0 

1901, 

.503,000 

24 

5.0 

1873, 

175,500 

230 

131.1 

1902, 

509,000 

15 

3.0 

1874, 

181,300 

289 

159.0 

1903, 

515,000 

19 

3.0 

1875, 

187,200 

227 

121.0 

1904, 

524,000 

18 

3.0 

1876, 

193,024 

130 

67.0 

1905, 

5.34,000 

16 

3.0 

1877, 

205,000 

173 

84.0 

1906, 

544,000 

11 

2.0 

1878, 

211,300 

116 

55.0 

1907, 

560,000 

15 

3.0 

1879, 

217,400 

236 

109.0 

The  eiJect  of  improved  sanitation  i.s  to  decrease  the  virulency 
and  dose  of  infection,  and  for  this  reason  there  follows  a  decreased 
severity  of  illness  and  a  decreased  percentage  of  mortality.  Not 
only  are  these  facts  true  of  the  cities  just  named,  but  it  is  also  true 
that  the  severity  and  mortality  of  typhoid  fever  are  steadily 
decreasing  all  over  the  world,  as  is  shown  by  the  following  inter- 
esting tables  of  Dreschfeld  in  regard  to  England  up  to  1892  in 
general  and  London  and  ^Manchester  up  to  1907,  the  statistics 
since  1892  being  collected  by  the  authors. 

A  similar  diminution  in  mortality  has  occurred  in  Chicago, 
Berlin,  New  York,  and  Philadelphia. 


1  This  table  is  taken  from  Pettenkofer"?  "Munich  a  Heahhy  City,"'  up  to  1887  inclusive, 
after  1887  from  returns  obtained  from  the  Statistical  Bm-eau. 


20 


GEXERAL  CONSIDERATIONS 


Annual  Mortality,  per  Million  Persons  Living,  from  Fever  in 

England. 


I'eriod. 


Enteric  cases. 


1838 1228 

1839 1010 

1840 1089 

1841 932 

1842 1004 

1843 

1844 

1845 

1846 

1847 1807 

1848 1266 

1849 1044 

1850 865 

1851 997 

1852 1022 

1853 1008 

1854 1015 

1855 875 

1856 847 

1857 988 

1858 918 

1859 806 

1860 652 

1861 767 

1862 919 

1863 874 

1864 960 

1865 1089 


Period.  Enteric  cases. 

1806 986 

1807 778 

1868 895 

1869 390 

1870 388 

1871 371 

1872 377 

1873 376 

1874 374 

1875 371 

1876 309 

1877 279 

1878 306 

1879 231 

1880 261 

1881 212 

1882 229 

1883 228 

1884 236 

1885 175 

1886 184 

1887 185 

1888 172 

1889 176 

1890 179 

1891 168 

1892 137 


Death-rate  from  Enteric  Fever  in  London  and  Manchester 
PER  Million, 


Year. 

1871 
1872 
1873 
1874 
1875 
1876 
1877 
1878 
1879 
1880 
1881 
1882 
1883 
1884 
1885 
1886 
1887 
1888 
1889 


London.  Manchester.   Year. 


267 

450 

1890 

242 

400 

1891 

269 

460 

1892 

256 

390 

1893 

235 

440 

1894 

217 

420 

1895 

251 

290 

1896 

283 

310 

1897 

229 

180 

1898 

186 

260 

1899 

254 

170 

1900 

252 

250 

1901 

247 

200 

1902 

234 

190 

1903 

150 

170 

1904 

154 

290 

1905 

151 

310 

1906 

169 

330 

1907 

130 

310 

London.  Manchester. 


146 

270 

132 

370 

102 

240 

161 

250 

147 

170 

143 

180 

130 

220 

132 

180 

131 

220 

180 

130 

170 

140 

118 

140 

126 

120 

83 

170 

65 

120 

53 

90 

57 

140 

40 

60 

DIMINUTION   <>!<'   MOIU'.IDITY    AND   MOIiTAlJTY 


21 


Figs.  2  and  .'>  illiislnilc  \\\v  rruirkcd  dccmasc  of  inorhdily  IVoiri 
typhoid  fever  in  I'crliii  id'Icr  I  lie  water  supply  was  fillcred.  'J'he 
decrease  in  mortality  in  IMiiladelpln'a  is  sliown  in  the  fli;ir(  ^Fig.  4) 
in  broken  and  conij)lete  lines. 

In  rhiladelphia  after  1898  the  morbidity  rate  advanced   until, 


Fir;.   1 


1 
1,000 


1 

2,000 


1 

3,000 


1 

4,000 


1 
5,000 


1 
6,000 


1 

7,000 


1 

,000 


1 

9,000 


10,000 


00 

CO 
00 

CO 
00 

i 

00 

in 

Ol 
CO 

CO 

CO 

00 

CO 

CT) 
CO 

§ 

5 

CM 
O 

8 

en 

s 

ID 

1 

■ 

1 

■ 

1 

J 

■ 

J 

1 

ll 

r 

1 

r 

1 

1 

1 

1 

Mortality  in  Chicago  of  typhoid  fever.  In  1891  and  1S92  the  water  was  contaminated 
with  sewage  and  the  death-rate  was  about  1  to  450  to  1500.  With  a  change  in  water 
supply  the  mortality  has  fallen  to  1  to  6000  or  even  1  to  9000.     (Seibert.) 


22 


GENERAL  COXSIDERATIONS 


in  1900,  we  find  llu'  iiiuiilicr  of  cases  recorded  a.s  9721.  Tliere  were 
1063  deaths,  giviii":  a  mortality  rate  of  only  10.93  per  cent.,  which, 
with  the  exce})tioii  of  the  rate  for  1905  (10. .jS  per  cent.),  is  the 
lowest  mortality  rate  for  this  disease  that  riiiladelphia  has  known. 
The  decrease  in  the  mimhcr  of  typhoid  fever  patients  reported  in 
1907  and    1908  was  dne  to   the  imjiroved  water  supply  in  tho.se 


Fig.  3 


OD 

il    5S    1-    :/• 

■*   ■^   ^   -* 

oe    OO    3D    C« 

:«^ 

o 

X 

1 
1 

i 

1000 

I 

~'U00 

1 

.JOOO 

1 

i 

4000 

1 

5U00 

1 
0000 

1 
rooo 

1 

8000 

1 

!)C00 

1 

1001  Ml 

1 

»   «>    a»   QO    QC    oc   on    a>    »   an 


1000 

2000 

3000 

4000 

5000 

COOO 

rooo 

8000 

9000 

10000 1 

-p 

■n 

■ 

J 

I'lo.  2. — .Mortality  of  tyi>lioici  fever  in  Berlin  before  supply  of  ilrinkitiK  water  was  filteied. 
In  tlie  decade  1843  to  18.53  tlie  average  yearly  mortality  was  1  i)er  900  of  inhabitants. 
l''iG.  3. — Mortality  of  tj-phoid  fever  in  Berlin  after  water  was  filtered.     (Seibert.) 


Ut^' 


DIMINUTION   ()!■•   M(  ihT.I  I )!'!' V    AND    MOiriMJIV 


2:', 


Vu:.  4 


NUMBER 

OF 
CASES. 

2 

1 

01 
1 

i 

00 

00 

to 

00 

3! 

00 

IjO 

s 

00 

00 

00 

00 

g 

0 

O) 

1 

1 

1 

i 

1 

1 

i 

BETWEEN 

UUOO-JOJOO 

25 

t 

9100-9600 

24 

A 

8600-9100 

23 

• 

\\ 

8100-8600 

22 

A 

'\ 

7600-8100 

21 

1 
\ 

\ 

^     I 

7100-7600 

20 

1 
\ 

^ 

\   1 

6600-7100 

19 

\ 
1 

1 

V. 

V 

1 

I 

6100-6600 

18 

' 

\ 

V. 

J 

\ 

5600-6100 

17 

\l 

\ 
\ 

\ 

5100-5600 

16 

V 

\/ 

y'^> 

■> 

, 

J 

4000-5100 

15 

* 

• 

V 

\ 

I 

i 

/ 

i  1 

4100-1600 

14 

A 

k 

J 

\ 

y 

( 

' 

3600-4100 

13 

J 

\ 

y 

\. 

r 

/ 

/\i 

3100-3600 

12 

4 

V 

A 

r 

\ 

V 

s 

\ 

/ 

i 

2600-3100 

11 

\ 

V 

A 

/ 

V, 

w 

\ 

.^ 

/ 

2100-2600 

10 

1 

V 

^*s 

V 

I* 

w 

rvi    v  J,-*  i    i    1 

Chart  showing  the  morbidity  and  mortality  of  typhoid  fever  in  Pliiladelphia.  Xotwith- 
.standing  the  increased  morbidity,  it  will  be  seen  from  the  dotted  line  that  the  mortality 
per  cent,  has  constantly  decreased.      Solid  line,  morbidity.     Dotted  line,  mortality. 


Typhoid  Fever  in  Philadelphia. 

Year.  Cases. 

1888 3573 

1889 4631 

1890 3182 

1891 " 3531 

1892 2304 

1893 2519 

1894 2357 

1895 2748 

1896 2490 

1897 2994 

1898 4749 

1899 7985 

1900 3227 

1901 3669 

1902 5006 

1903 8701 

1904 6587 

1905 6458 

1906 9721 

1907 6712 

1908 3562 


Mortality 

Deaths. 

Per  cent. 

785 

21.9 

736 

15.8 

566 

20.9 

683 

19.3 

440 

19.1 

456 

18.1 

370 

15.7 

469 

17.0 

402 

16.1 

401 

13.3 

566 

11.9 

948 

11.87 

449 

13.91 

444 

12.10 

588 

11.74 

957 

10.99 

744 

11.29 

684 

10.58 

1063 

10.93 

890 

11.65 

533 

14.96 

24 


GENERAL  CONSIDERATIONS 


sections  of  the  city  which  received  filtered  water.  The  decrease  in 
the  wards  of  the  city  suppHed  entirely  by  filtered  water  has  been  most 
satisfactory,  amounting,  in  several  instances,  to  60  per  cent,  of  the 
former  rate.  It  is,  of  course,  hardly  to  be  expected  that  any  marked 
decrease  in  the  number  of  typhoid  fever  cases  will  be  observed  until 
the  entire  city  is  supplied  with  properly  filtered  water. 


Fig.  6 


NUMBER 

OF 

CASES 

>- 
-j  ^, 

"■  o 

o  ^ 

cc 
< 

u 

>- 

00 
00 
00 

1 

o 

00 

Si 

00 

CJ 

00 

CO 

CO 

CO 

in 

CT> 

OD 

CO 

cn 

00 

00 
00 

00 

8 

1 

CM 
O 

CO 
o 
en 

S 

en 

in 
o 

a> 

U3 
O 

1- 

o 

00 

o 

300-320 
•^.SO-SOO 

23 
?? 

— 

= 

^ 

^ 

^ 

= 

= 

= 

= 

= 

= 

= 

= 

= 

= 

= 

= 

= 

260-280 
240-260 
220-240 

21 
20 
19 

— 

= 

= 

^ 
^ 

^ 

= 

^ 

^ 

= 

1 

= 

^ 

aE 

= 

1 

1 

200-220 
180-200 
160-180 

17 
16 

— 

= 

^ 

= 

SI 

=i 

^ 

= 

1 

V 

zi; 

i 

^ 

110-160 

15 

^ 

^ 

:=:= 

— Y 

= 

S 

= 

u 

= 

= 

= 

— ni 

^ 

= 

= 

120-140 

14 

^ 

^ 

z=z 

1=1 

^ 

=. 

m 

m 

^ 

= 

=i=^ 

^ 

:= 

= 

100-120 

13 

=^ 

=^ 

= 

= 

= 

e 

= 

=z 

= 

= 

= 

^ 

= 

P 

^ 

^ 

80-100 

12 

^ 

^ 

= 

^ 

= 

= 

^= 

^= 

S 

= 

— t 

= 

S 

= 

60-80 

11 





1 

= 



i 

^ 

= 



M 

1 

E 

3s; 

= 

w 

1 

= 

^ 

20-40 

9 

— 

= 

= 

^ 

^ 

= 

= 

M 

^ 

= 

^ 

= 

= 

ii:i 

Chart  showing  increased  morbidity  but  decreased  mortality  per  cent,  at  the  Philadelphia 
Hospital  for  twenty  years  (1888-1908).    Solid  line,  morbidity.     Dotted  line,  mortality. 

These  statistics  for  Philadelphia  go  back  as  far  as  the  compara- 
tive records  extend,  and  do  not  include  the  1348  soldiers  with 
typhoid  fever  who  returned  from  the  Spanish-American  war  in 
1898,  but  only  the  regular  population  of  the  city.  If  the  soldiers 
are  added  to  the  number  of  1348,  we  find  that  6097  cases  of 
enteric  fever  occurred  in  Philadelphia  in  1898.  The  mortality 
of  the  city  population  was  11.91,  that  of  the  soldiers,  5.41,  which 
would  make  the  total  percentage  10.47  in  6097  cases.  The  low 
mortality  of  the  soldiers  is  a  tribute  to  hospital  treatment,  for  in 
many  cases  these  men  were  transported  hundreds  of  miles  when 
very  ill,  and,  as  a  rule,  had  not  had  the  food  and  care  which  are  so 
necessary  to  the  safe  conduct  of  a  typhoid  case 


DIMINUTION   O/''   MOIUilhrrV    AN  I)    MOiri'MJ'I'Y 


25 


NUMBER 

OF 

CASES. 

1 

o 
tjl 

00 

CM 
00 

CO 

CO 

00 

UO 
00 

00 

00 

CO 

i 

i 

1 

i 

1 

i 

i 

1 

2500 

r 

s 

2100 

/ 

\ 

2300 

) 

, 

2200 

V 

'^. 

2100 

1 

V 

s. 

2000 

/ 

1900 

/ 

1800 

/ 

1700 

/ 

1600 

/ 

1500 

A 

1 

' 

1400 

A 

A 

J 

1300 

A 

A 

/ 

V 

1200 

/ 

\/ 

V 

/ 

1100 

/ 

V 

\ 

s 

/ 

1000 

\ 

/ 

■^ 

900 

\ 

V  - 

/^ 

800 

V 

Chart  showing  increasing  number  of  cases  annually  in  New  York.     Part  of  the  increase 
at  least  is  due  to  great  increase  of  population. 


Typhoid  Fever  in  Manhattan 

AND  Bronx 

(Old  City  of 

New  York).^ 

Year.                          Cases.           Deaths. 

Death-rate. 

Case  fatality. 
Per  cent. 

Population. 

1893  ....      1008                 381 

2.16 

37.7 

1,758,010 

1894   . 

792                 326 

1.80 

41.1 

1,809,353 

1895   . 

965                 322 

1.71 

33.3 

1,879,195 

1896   . 

1002                 297 

1.53 

29.6 

1,934,077 

1897   . 

1004                 299 

1.50 

29.7 

1,990,562 

1898   . 

1535                 376 

1.83 

24.4 

2,048,830 

1899   . 

1290                 294 

1.38 

22.7 

2,117,106 

1900   . 

1759                 372 

1.81 

21.1 

2,055,714 

1901    . 

1945                 412 

1.94 

21.1 

2,118,209 

1902   . 

2629                 400 

1.83 

15.2 

2,182,836 

1903   . 

2462                 350 

1.55 

14.2 

2,249,680 

1904   . 

2136                 309 

1.33 

14.4 

2,318,831 

1905   . 

2194                 310 

1.21 

14,1 

2,390,382 

1906   . 

2014                 369 

1,50 

13.3 

2,464,432 

1907   . 

2771                 420 

1.65 

15.1 

2.541,084 

1  This  table  is  taken  from  an  article  entitled 
during  1905,"  by  J.  S.  Billings,  Jr.,  M.D. 


'Typhoid  Fever  in  the  City  of  New  York 


26 


GENERAL  CONSIDERATIONS 


These  tables,  as  to  mortality,  are  supported  bv  tlie  statement  of 
Billings,  that  in  Norway  from  1888  to  1891  the  mortality  from 
typhoid  fever  was  755  in  74G7  cases,  or  less  than  10  per  cent.  In 
the  ]\Iaiilstone  epidemic  the  death-rate  in  1885  cases  was  only  7.5 
per  cent.,  and  a  similar  mortality  obtained  at  Plymouth,  Pa.  The 
death-rate  in  the  Worthing  epidemic  of  about  lOCO  cases  was  13 
per  cent. 

Fig.  7 


ANNUAL 
DEATHS 
PERCENT 

00 
00 
CO 

CC 
00 

o 
CO 

5i 
CO 

CM 

o 
00 

CO 

CO 

CO 

in 
CO 

GO 

CO 

00 

at 

Ol 
CO 

o 
o 

5 

Ol 

CM 
O 

CO 

o 

Ol 

o 

Ol 

o 

en 

o 

Ol 

o 

Ol 

41 

A 

40 

A 

39 

/ 

\ 

38 

/ 

\ 

37 

/ 

\ 

36 

/ 

\ 

35 

/ 

\ 

34 

/ 

\ 

33 

\ 

/ 

\ 

32 

\ 

A 

' 

\ 

31 

\ 

A 

/ 

\ 

30 

\        , 

r     ^ 

\ 

y 

29 

V 

V 

\ 

28 

Y 

V 

^\ 

27 

\ 

26 

I 

25 

\ 

24 

\ 

23 

V, 

22 

\ 

21 

\ 

/ 

20 

\ 

19 

\ 

18 

) 

fs 

17 

\ 

r 

s 

16 

\ 

1 

15 

V 

/ 

14 

**>»- 

-4 

Chart  showing  decreasing  death-rate  from  typhoid  fever  in  New  York  City. 

Bryant^  states  that  out  of  608  cases  treated  in  Guy's  Hospital 
from  1879  to  1893,  14  per  cent.  died. 

Again,  in  the  Gazette  Medicale  des  Hopitaux  of  July  10,  1890, 
we  learn  that  a  collective  investigation  in  France  showed  that, 
whereas  in  the  period  from  1866  to  1881  the  mortality  from  typhoid 


I  Bryant.     Guy's  Hospital  Reports,  1893. 


DJMINUrioS   OF   MOHIilhll'V   A  SI)   MOiriALITY  27 

Wiis  21..')  JHT  ccnl.;  fioiii  ISS2  (o  ISSS  j(.  was  I  I.I  \n-y  rent.,  and  In 
ISSO,  VAJ)  per  ccnl. 

We  may  assume,  then,  tliat  the  (miinarv  mortality  of"  typhoid 
fever  is  at  ])reseiit  less  than  IT)  per  cent,  in  the  general  run  o'i  cases, 
and  that  in  jrood  hospitals  and  |)rivate  practice  with  ^^ood  nursing, 
it  varies  from  1  to  10  per  cent.,  the  more  so  as  many  years  ago, 
before  the  disease  had  become  moch'fied,  Murchision  })laccd  it  at 
17.45  among  27,951  cases  in  England. 

The  following  statistics  of  patients  treated  by  general  methods 
show  this  to  be  true,  and  with  or  without  baths  a  simihir  decrease 
in  mortality  is  evident: 

Cases. 

Basel  (Liebernieister) 22.3 

Basel  (Liebermeister) 239 

Maidstone,  England 1,88.5 

Boston  (Mason) 676 

Homerton  (Collie) 677 

Glasgow  (Collie) 618 

Soci^t(5  Mddieale  des  Hopitaux  (1879)i  1,979 

Jaccoud 66.5 

Riess 900 

Boston  (Shattuck) 237 

Germany  (?)  Brand  has  collected       .       19,017 


Mortality. 

Per  cent. 

Treatment. 

11.7 

Calomel. 

14.6 

Iodide. 

7. .5 

General. 

10.4 

General. 

9.5 

General. 

8.2 

General. 

12.47 

10.8 

General. 

7..5 

Tepid  baths. 

9.8 

Expectantly  and  cold 

sponging. 

7.8 

All  kinds  of  cold 

baths. 

27,116  10.02 

In  other  words,  27,116  cases  in  Switzerland,  America,  England, 
Germany,  and  France  show  that  good  nursing  and  careful  non- 
meddlesome  treatment  will  give  a  mortality  of  al^oiit  10  per  cent. 
The  wide  distribution  of  these  cases  and  the  large  number  of 
clinicians  o-ive  us  a  standard  averao-e. 

At  Basel,  in  1S73,  under  the  cold  bath,  there  were  163  cases, 
with  a  mortality  of  10.4  per  cent. ;  during  the  same  year  at  Glas- 
gow without  baths,  275  cases,  with  a  mortality  of  9.4  per  cent.; 
and  305  at  Homerton,  with  a  mortality  of  9.5  per  cent.  In  1S74 
at  Basel  the  water  cases  were  200,  with  a  mortality  of  10.5  per 
cent. ;  at  Homerton,  372,  with  a  mortahty  of  9.6  per  cent. ;  at  Glas- 
gow, 343,  with  a  mortality  of  7  per  cent. 

1  These  statistics  are  based  upon  the  fact  that  twenty-one  chiefs  of  hospital  service 
reported  to  the  Societe  M^dicale  des  Hopitaux  (1890)  916  cases  with  114  deaths,  or  12.44 
per  cent,  under  general  treatment;  and  for  1888  and  1889,  this  report  also  mentions  1063 
cases  so  treated,  with  133  deaths,  or  12.51  per  cent. 


2S  GENERAL  CONSIDERATIONS 

Mortality 

No.  of  cases.  Treatment.  Per  cent. 

Basel     (1873) 163            Bath  10.4 

Glasgow .   " 275             General  9.4 

Homerton " 305             General  9.5 

Basel      (1S74) 200             Bath  10.5 

Glasgow      " 343             General  7.0 

Homerton  " 372             General  9.6 

More  recently  other  epidemics  have  shown  the  same  decrease 
in  mortahty  rates.  In  the  New  Haven  (Conn.)  epidemic  of  1901 
there  were  514  cases  and  a  mortahty  rate  of  12.2  per  cent.  In  the 
Ithaca  epidemic  of  1903,  there  w^ere  1350  cases  and  a  mortahty  rate 
of  6.09.  In  the  Scranton  epidemic  of  1906  there  were  1155  cases 
and  9.9  per  cent,  mortahty,  while  in  the  epidemic  at  Butler,  Pa.,  in 
1903,  there  were  1270  cases,  with  the  very  low  mortality  of  4.4  per 
cent. 

Of  the  fact  that  a  change  in  type  has  taken  place  in  enteric 
fever  we  do  not  think  there  can  be  any  doubt,  and  no  one  who  has 
watched  the  disease  during  the  last  twenty-five  years,  or  even  for  a 
shorter  period  than  this,  can  fail  to  note  the  difference  in  its  char- 
acter. Particular  attention  has  been  called  to  this  fact  by  Sidney 
Phillips^  and  James  F.  Goodhart.^  The  latter  writer  says:  "I 
agree  in  toto  with  what  Dr.  Sidney  Pliillips  said  to  us,  that  'typhoid 
fever  tends  to  vary  with  the  conditions  associated  with  its  origin, 
and  though  such  variations  are  slight  individually  and  gradual  in 
evidence  in  their  sum,  they  suffice  in  time  to  produce  a  considerable 
modification  of  the  original  disease.'  There  is  considerable  differ- 
ence in  the  symptoms  described  fifty  or  even  twenty-five  years  ago 
and  those  occurring  today.  The  difference  is  marked  in  the 
lessened  severity  of  the  abdominal  symptoms;  the  tongue  is  now 
often  moist  throughout  the  disease,  instead  of  dry  and  baked; 
tympanites  and  diarrhoea  are  much  less  pronounced ;  probably  also 
hemorrhage  and  perforation  are  less  common;  tremors  and  dilata- 
tion of  the  pupils  are  now  uncommon;  and,  instead  of  noisy,  active 
delirium,  the  mind  is  often  clear  tliroughout  even  fatal  cases.  The 
typhoid  state  with  the  patient  sunk  deep  in  bed,  unable  to  move 
himself  and  unconscious  or  semiconscious  for  days,  is  now  quite 

1  Phillips.     British  Medical  Journal,  November  12,  1898. 

2  Goodhart.     Ibid.,  January  28,  1899. 


MOIUilDI'I'V    IS    (IIILhllOOl)  20 

except ioiiul.  Dr.  I'liillips  iiltrihuU's  this  'to  ;i  lessened  tei.<leney  to 
iilceriition  of  the  iMt(>stines,'  iirxl  ar^nies  that  if  so  iniu-h  variation  of 
type  liiis  taken  phiec  in  m,  (piarter  of  a  eentiiry,  mueh  more  hits  ;<one 
on  in  fifty  years,  and  that  where  eon. Hi  ions  existed  such  as  made 
typhus  rife,  th(;  distinctive  features  of  typhoid  may  well  have  been 
alfected,  and  that  iu  this  is  possibly  to  be  found  the  cxi)lanation 
that  the  separate  diseases  were  regarded  as  one." 

Morbidity  in  Childhood.— In  this  connection  the  rpiestion  of 
the  frcqucncij  of  lijphoid  fever  in  children  may  be  considered.  At 
first  sight  it  would  appear  that  in  this  class  of  patients  it  is  a  more 
common  disease  than  formerly,  but  this  is  only  because  it  was  pre- 
viously not  recognized  and  recorded. 

Typhoid  fever  in  children  is  by  no  means  as  rare  as  has  been 
supposed.  While  the  earlier  years  of  life  seem  to  be  blessed  with  a 
relative  immunity  to  the  disease,  there  is  no  doubt  that  it  often 
occurs  in  a  mild  form  and  is  not  correctly  diagnosticated.  A  young 
child  sickens,  has  fever,  is  wretched,  has  moderate  diarrhtea  or 
constipation,  and  a  coated  tongue.  Debility  is  rapidly  developed, 
the  stomach  becomes  irritable,  and  the  fever  is  j^ersistent,  even 
though  it  may  not  be  high.  After  an  illness  lasting  for  from  a  few 
days^'to  several  weeks,  the  child  gradually  recovers,  and  the  diag- 
nosis originally  made  is  adhered  to,  namely,  that  the  case  has  been 
one  of  "simple  catarrhal  fever."  The  longer  one  practises  medi- 
cine the  more  strongly  the  idea  develops  that  such  a  thing  as  "simple 
catarrhal  fever"  does  not  exist  as  an  entity,  and  that  this  term 
covers  a  multitude  of  diagnostic  sins.  As  was  pointed  out  by 
Liebermeister  years  ago,  typhoid  fever  may  occur  even  in  adults 
with  these  mild  symptoms,  and  be  called  "catarrhal  fever." 

It  may  be  laid  down,  however,  as  a  rule,  that  the  younger  the 
child  the  less  likely  is  it  to  have  enteric  fever,  and  that  the  younger  the 
child,  the  more  favorable  the  prognosis.  In  other  words,  the  older 
the  child,  the  more  grave  the  prognosis.  On  the  other  hand,  it  is 
only  fair  to  state  that  Rocaz^  believes  that  while  the  duration  of  the 
fever  in  children  is  shorter  than  in  adults,  the  fever  itself  is  apt  to 
be  excessive;  that  the  prognosis  is  grave  under  three  years,  less 

1  Rocaz.     Annales  de  la  Polyclinique  de  Bordeaux,  1S97. 


30  GENERAL  CONSIDERATIONS 

grave  at  four  years,  and  only  less  tjravo  tlian  in  adults  when  the 
child  is  above  five  years  of  age. 

This  (juestion  of  how  frecjuently  typhoid  fever  does  occur  in 
children  is  of  great  importance.  At  the  head  of  those  who  advo- 
cated the  view  in  the  past  that  it  was  comiuon  we  have  Ashley  and 
Wright/  who  asserted  that  "children  and  young  people  are  more 
susceptible  to  typhoid  fever  than  are  adults,  though  it  is  not  common 
in  children  under  three  years  of  age."  This  is  certainly  an  exces- 
sive statement,  although  Pepper'"  stated  that  typhoid  fever  was  far 
more  common  in  early  life  than  was  generally  recognized.  Henoch 
recorded  370  cases  and  26  autopsies  in  children  from  this  disease, 
and  Barthez  and  Sanne  state  that  the  disease  is  as  frecjuent  among' 
children  as  among  adults. 

On  the  other  hand,  an  immense  amount  of  evidence  has  l)een 
advanced  to  prove  that  the  disease  was  so  rare  as  to  be  almost  a 
curiosity  in  children.  Thus,  William  Perry  Northrup  has  taken 
the  statistics  of  the  New  York  Foundling  Hospital,  the  New  York 
Infant  Asylimi,  the  Children's  Hospital  of  Philadelphia,  and  found 
that  in  the  twenty  years  at  the  New  York  Foundling  Hospital,  with 
1800  cases  under  care,  1100  of  which  were  boarded  in  the  country, 
returning  to  the  hospital  when  ill,  not  a  single  case  had  been  seen, 
by  himself,  J.  Le^^^s  Smith,  and  O'Dwyer.  Further,  in  2000 
autopsies  on  children  Northrup  did  not  find  a  case  (perhaps  be- 
cause typhoid  fever  rarely  brings  a  child  to  autop.sy),  and  during 
an  epidemic  in  Stamford,  Conn.,  in  1895,  out  of  400  cases  at  all 
ages,  but  four  cases  of  enteric  fever  developed  under  four  years  of 
age. 

Holt^  states  that  he  has  never  met  witli  enteric  fever  in  a  child 
under  two  years  of  age.  He  never  saw  a  case  in  the  New  York 
Infant  Asylum  in  a  service  of  eight  years,  although  15,000  cases 
were  admitted  in  that  time.^  One  case  was  admitted  to  the  Babies' 
Hospital  in  seven  years  at  the  age  of  two  and  one-half  years. 

In  this  connection  it  is  interesting  to  note  that  Taupin,"  writing 

1  Ashley  and  Wright.     Diseases  of  Cliildreii. 

2  Pepper.     American  System  of  Medicine,  vol.  ii. 
'  Holt.     Diseases  of  Cliildren. 

*  Probably  all  these  did  not  come  under  his  term  of  service. 

'"  Taupin.     Journal  des  Connaissances  Mdd.  et  Chir.,  1839,  No.  7. 


MOh'lilDI'l  Y   IS   (IIILhlloOh  31 

.seventy  years  ago,  stutcd  lli;i(  the  rjnily  of  (his  IVvcr  in  fliildicn 
was  more  apparent  than  real,  mid  poinlcd  out  di;i(  die  mild  mani- 
festations of  the  disease  were  overlooked. 

Nothwithstandinf);  tliese  statements  to  [\\v.  ronfrary  we  find  that 
typhoid  fever  does  ocem-  (jiiite  fre(|M('n(ly  in  c  liil(h'en  in  the  hands  of 
some  practitioners.  Thus,  Foi(  lihcimer'  treated  70  cases  in  ISS-S  in 
one  epidemic,  and  Morse,  in  analyzinf^  2S4  cases  in  the  Boston  City 
Hospital  in  which  this  (hsease  appeared,  found  3  un(Jer  five  years 
of  age,  77  between  five  and  ten  years,  and  204  between  ten  and 
fifteen  years.  Holt  cjuotes  070  cases  of  enteric  fever  in  rhil.lren 
collected  from  eight  authors  whose  names  he  does  not  give.  Of 
these  970  cases,  8  per  cent,  occurred  under  five  years;  42  per  cent, 
between  five  and  ten  years,  and  50  per  cent,  between  ten  and  fifteen 
years.  He  also  quotes  an  epidemic  of  ]  1.5  persons,  of  whom  three 
were  under  two  years  of  age. 

Wightman^  has  recorded  24  cases  of  typhoid  fever  in  children 
under  thirteen  years  of  age;  3  of  these  died,  and  typical  spots 
were  seen  in  15;  constipation  was  present  in  10,  and  typical  stools 
in  only  3  cases.  So,  too,  Davis^  has  recorded  33  cases  in  children, 
all  under  ten  years  of  age,  and  in  all  hut  3  the  disease  developed 
abruptly. 

Ssokolow,^  in  a  study  of  581  cases  of  typhoid  fever,  the  majority 
of  which  occurred  in  cases  between  four  and  ten  years  of  age, 
found  that  the  disease  was  abortive  in  4,3-^er  cent.,  mild  in  2u 
per  cent.,  ordinary  in  51  per  cent.,  and  severe  in  18  per  cent. 
In  3.6  per  cent,  there  was  an  abrupt  onset  AAith  vomiting,  and  in 
3.2  per  cent,  abrupt  with  a  chill;  diarrhcea  occurred  in  only  10 
per  cent. 

Bridges  has  met  with  the  disease  in  infants  at  fifteen  and  eighteen 
months  of  age,  and  Bond  saw  eleven  children,  affected  in  one  house 
epidemic,  between  the  ages  of  three  and  twelve  years.  Read''  has 
collected  22  cases  between  four  and  one-half  months  and  ten  years, 
and  Griffith  reports  cases  at  three,  seven,  eleven,  and  thirteen  years. 

'  Forchheimer.     American  Lancet,  March,  1SS9. 

-  Wightman.     British  Medical  Journal,  May  5,  189-t. 

'  Davis.     Alabama  Medical  and  Surgical  Age,  August,  1S94. 

*  Ssokolow.     Centralblatt  fiir  innere  Med.,  May  IS,  1S95. 

'  Read.     Brooklyn  Medical  Journal,  October,  1S90. 


32  GENERAL  CONSIDERATIONS 

Griffith  and  Ostheimer^  have,  since  Griffith's  earlier  report,  collected 
418  cases  of  typhoid  fever  in  children  under  two  and  one  half  years 
of  age.  One  hundred  and  eleven  of  these  cases  were  under  one 
year  of  age.  From  a  total  of  278  cases  142  died.  Twenty  of  the 
418  cases  were  born  with  the  disease,  hut  the  greatest  number 
occurred  during  the  second  year.  Porter  and  Helbron^  have 
published  03  instances  of  typhoid  fever  in  children,  and  state  that 
in  the  majority  of  the  cases  a  definite  prodromal  period  was  noted, 
while  in  three  the  onset  was  sudden.  A'omiting  was  a  common 
initial  symptom,  as  was  pain  and  tenderness  of  the  abdomen. 
Diarrhoea  was  frecjuently  noted  as  having  been  present  from  the 
first.  Rose  spots  were  observed  in  54  of  the  03  cases  and  were  most 
often  noted  on  the  seventh  day;  52  of  the  patients  of  this  series 
had  palpable  spleens. 

England  records  one  case  at  eight  months  of  age  and  Boobbyer 
one  in  an  infant  of  eight  montlis.  IMurchison  recorded  one  case 
at  six  months.  Ogle  has  recorded  a  case  at  four  and  one-half 
months  and  Fuller  one  at  five  months. 

Further  than  tliis,  Dr.  Mart,^  of  German,  Oliio,  has  recorded 
the  fact  that  in  six  years  he  had  treated  seventeen  cases  of  unques- 
tionable tj^hoid  in  children  ranging  from  fourteen  months  to  five 
years  of  age;  that  three  of  these  cases  were  less  than  twenty-four 
months  old,  and  in  each  instance  there  were  other  members  of  the 
family  sick  with  the  fever  at  the  same  time,  showing  that  the 
infection  was  present  in  the  household. 

H.  J.  Lee,^  of  Cleveland,  reports  a  case  of  typhoid  fever  in  an 
infant  six  months  old,  and  states,  although  he  does  not  give  the 
reference  for  the  same,  that  he  finds  one  case  reported  as  young  as 
four  and  one-half  months,^  another  at  six  months,  and  a  good 
many  under  two  years. 

O'Malley"  records  three  cases  of  typhoid  fever  at  twenty-one 
months,  three  years,  and  six  years  in  one  family. 

'  Griffith  and  Ostheimer.     American  Journal  of  the  Medical  Sciences,  September,  1902, 
vol.  Ixxiv. 

2  Porter  and  Helbron.     Archives  Gdn^rale  de  M^decine,  1906. 

'  Mart.     Cleveland  Medical  Gazette,  vol.  xii,  p.  510. 

*  Lee.     Cleveland  .Journal  of  Medicine,  1897,  vol.  ii,  p.  400. 

'  Probably  Ogle's  case. 

8  O'.Malley.     University  Medical  Magazine,  1896-97,  p.  6.37, 


MORHIDITV  IN   dl I Ll)ll< >< >h  '.'/^ 

Not  only  rnjiy  typhoid  IVvcr  occur  in  very  yonn;/  cliildrcn,  but 
it  is  to  be  rcnicnil)crc(|  lluit  tlii.s  source  of  infecfion  nmy  cause  tfie 
disease  ainon<^-  ndulls.  Tlnis  i'oobhyer'  records  ;in  in^t;lncc  in 
which  out  of  a  family  of  ei<(ht  persons  five  became  infected  through 
an  infant  of  eight  months.  The  child  had  been  restless  and  had 
constant  diarrhoea,  but  the  fact  that  it  was  suffering  from  typhoirJ 
fever  was  not  recognized. 

That  severe  ty})hoid  fever  may  occur  very  early  in  life  is  shown 
by  the  statement  of  Osier,  that  j)erforalion  of  the  bowel  from  this 
cause  has  occuri'cd  in  a  child  (Ia'c  days  old,  aiid  lvirl<'  has  rcj)orted 
a  case  to  Keating  of  fatal  inteslinal  licniorrlian(-  due  to  typhoid 
fever  at  twenty-two  months. 

Griffith"  has  also  reported  0  cases  of  perforation  during  typhoid 
fever  in  children,  while  Elsberg^  found  25  cases  in  cliildren  under 
fifteen  years  of  age,  in  a  series  of  2S9  operations  for  perforation. 
Griffith*  was  able  to  find  records  of  94  instances  of  perforation  in 
children  ill  of  typhoid  fever.  Czarnik^  reported  two  cases  in  which 
there  was  a  successful  operation  for  repair  of  the  perforation  during 
typhoid  fever  in  children.  Brelet''  found  in  the  literature  accounts 
of  30  sudden  deaths  during  typhoid  fever  in  children,  while  Velich^ 
noted  10  deaths  between  the  ages  of  three  and  thirteen  years  during 
this  disease,  and  quotes  Mousson's  statistics  of  60  cases  of  typhoid 
in  children,  with  one  sudden  death,  and  Stowell's  series  of  61  cases 
of  typhoid  in  children,  wdth  one  sudden  death.  Woodward*  has 
reported  two  cases  of  hemorrhagic  typhoid  fever  in  children,  which 
is  a  type  rarely  seen,  particularly  in  this  class  of  patients. 

Further  than  tliis,  Sbrana,^  who  has  treated  seventy-two  cases 
of  typhoid  fever  in  children  in  Tunis,  tells  us  that  a  symptom 
which  was  never  lacking  was  splenomegaly  appreciable  from  the 
fifth  or  sixth  day  of  the  fever.     The  nervous  symptoms  were  more 

1  Boobbyer.     British  Medical  Journal,  January  26,  1S90. 
-  Griffith.     Archives  of  Pediatrics,  January,  190S. 
'  Elsberg.     Quoted  by  Czarnik. 

*  Griffith.     Archives  of  Pediatrics,  January,  1908. 

^  Czarnik.     Lwowski  tygodnik  Lekarski,  1906,  No.  -40. 
6  Brelet.     Arch.  Gen.  de  M<?decine,  1906,  No.  3S. 
^  Velich.     Archiv  fiir  Hygiene,  No.  49,  p.  190. 

*  Woodward.     Archives  of  Pediatrics,  November,  1907. 

^  Sbrana.     Quoted  in  the  American  Journal  of  Obstetrics  for  March.   1S99,  from  the 
Archives  de  Med.  des  Enfance,  January,  1S99. 

3 


34  GENERAL   COXSIDERATIOXS 

marked  in  yirls  than  in  hoys,  'i'he  niortahty  was  11.1  per  cent., 
and  the  eoniphcations  were  meninoitis,  snppm'ation,  par()ti(h"tis, 
peritonitis  from  ])erforatioii,  purulent  j)lenrisy,  aj)hasia  histino-  as 
lonij^  as  three  weeks,  dihitation  of  the  stoniacli  (hu'inn-  coin  aU'scenee, 
and  orchitis. 

\Vurtz'  records  the  case  of  a  i;irl  of  cinlil  years,  who  (k'Vi'h)ped 
a  swelling  over  the  sternum  (hn-ini;'  tlie  second  week  of  typlioid 
fever.  Puncture  drew  pus  and  an  incision  gave  exit  to  a  neerosed 
pieee  of  the  sternum,  the  entire  body  of  the  hone  heinj^;  involved 
in  tile  necrotic  process.  Typlioid  hacilh'  were  demonstrated  iiiicro- 
seopieally  in  the  pus.  Deatli  oceurred  in  the  fifth  week.  At  the 
autopsy  an  abseess  lined  ])y  pyogenie  memlwane  was  found  l)etween 
the  sternum  and  pleura,  extending  upward  to  the  maiiubiium. 
There  was  bronchopneumonia  in  both  huigs,  and  in  the  ileum 
there  were  a  few  typhoid  ulcers,  tiie  rest  of  the  intestine  showing 
healino-;  the  rioht  arvtenoitl  cartilage  showed  a  chondritis. 
I  In  the  Maidstone"  epidemic  of  1S97  and  1S9S,  22  per  cent,  of 
the  cases  admitted  to  the  hospital  were  in  children  under  ten  years 
of  age,  and  52  per  cent,  were  under  fifteen  years. 

We  think  it  is  fair  to  conclude  therefore  that  Taupin's  assertion, 
in  1839,  that  typhoid  fever  is  not  a  rare  disease  in  children  is  correct. 

At  the  present  time  the  diagnosis  of  typhoid  fever  in  children 
must  rest  largely  upon  the  chance  development  of  the  character- 
istic rash  and  enlarged  spleen,  and  more  than  all  upon  the  Widal 
test,  or  positive  blood  culture,  for  the  moderation  in  all  the  symp- 
toms so  characteristic  of  the  affection  in  childhood,  and  the  fact 
that  a  swollen  spleen  and  liver  and  a  coated  tongue  with  fever  are 
so  commonly  met  with  in  various  children's  ailments,  make  an 
absolute  diagnosis  without  these  tests  in  many  instances  almost 
impossible. 

The  above  paragraphs  were  written  nearly  ten  years  ago,  and 
since  that  time  careful  study  and  a  review  of  the  literature  enforces 
upon  us  the  truth  of  the  statement  that  "typhoid  fever  in  children 
is  by  no  means  as  rare  as  has  been  supposed." 

■  Wurtz.  Quoted  in  the  American  Journal  of  Obstetrics  for  March,  1S99,  from  the 
Jahrbuch  f.  Kinderheilkunde,  vol.  xliv,  No.  1.  We  have  not  been  able  to  see  tlie  orifiinal 
article. 

-  Poole.     Guy's  Hospital  Reports.  1898.     Wrongly  labelled  on  cover  1890. 


MORIilDITY   IN   I'U/y; NANCY   AND  IN   l'(K'rM.   I./FI:        :>,:, 

Til  tlic  first  cdilioii  of  jlii.s  cssjiy  llircc  f)ji|((',s  wmihl  luivf  iiifliKJcd 
all  the  recorded  cases  of  typhoid  Ivvcr  in  children,  Ixit  during'  die 
ten  years  that  have  ela[)sed  the  siihjecl  has  iinderirone  f-arct'iil 
investigation,  and  al  present  i(  would  rcfpiire  an  entire  cjiapter 
to  review  the  lari^x-  nnniix-rs  ol"  cas«'s  of  inidonhletl  lyj>lioid  lever 
in  infants  and  yonn<r  children.  That  ty[)hoid  fever  rarely  brings 
a  child  to  antopsy  was  staled  in  the  first  edition  to  explain  why 
Northruj),  in  2(XJ()  antoj)sies  in  a  cin'Idren's  hospital,  failed  tf)  see  a 
case  of  this  disease.  More  recently  there  have  heen  an  inr-reasing 
number  of  auto})sies  uj)on  subjects  of  infantile  typhoid  fever  in 
which  the  lesions  were  unmistakable,  while  the  blood  cultures  from 
the  organs  and  mesenteric  glands  has  revealed  the  presence  of  the 
sj)eeific  bacillus  of  the  disease. 

So  many  cases  have  been  carefully  studied  in  chiMren,  not  only 
clinically  but  by  means  of  blood  cultures  as  well  as  by  the  Widal 
reaction,  that  there  can  be  no  doubt  that  many  cases  of  typhoid 
fever  in  children  have  been  overlooked  in  the  past.  Not  only  is 
this  true  of  children,  but  careful  researches  have  revealed  the  fact 
that  congenital  and  fd^tal  typhoid  fever  is  by  no  means  very  rare. 

Morbidity  in  Pregnancy  and  in  Foetal  Life. — Typhoid  fever  is 
not  common  in  pregnancy,  but  when  it  occurs  it  is  a  serious  matter, 
for  abortion  often  follows,  particularly  if  the  fever  be  high.  The 
percentage  of  abortion  is  about  56.  In  310  cases  collected  by 
Sacquin,  199  aborted.  The  mortality,  according  to  Brieger,  was 
19  in  91  cases,  and  according  to  Vinay,  17  per  cent,  in  183  cases. 

Typhoid  fever  may  also  affect  the  foetus  in  utero.  This  Fordyce 
has  proved,  and  he  also  asserts  that  the  cliild  may  survive.  It  is 
possible,  too,  for  it  to  escape  the  infection.  Flexner  has  examined 
such  a  case  for  Osier. 

Griffith  found  the  Widal  reaction  in  a  child  of  seven  weeks  whose 
mother  had  typhoid  fever  at  the  time  of  its  birth. 

So,  too,  Etienne^  has  recorded  the  examination  of  a  foetus  ex- 
pelled by  a  woman  in  the  fifth  month  of  pregnancy,  on  the  twenty- 
ninth  day  of  typhoid.  The  spleen  and  intestines  of  the  cliild 
showed  no  signs  of  the  disease,  and  the  placenta  was  healthy,  but 

1  Etienne.     Gazette  Hebd.  ile  Medecine  et  de  Cliirurgie.  1896.  No.  16. 


36  GENERAL  CONSIDERATIONS 

an  examination  of  the  blood  in  the  right  side  of  the  heart  and  of 
that  of  the  spleen  revealed  innumerable  typhoid  bacilli. 

Death  to  the  foetus  does  not  always  occur  as  a  result  of  prema- 
ture birth  due  to  typhoid  fever;  thus,  Touvenaint^  reports  a  case 
of  premature  birth  at  the  end  of  the  seventh  month,  the  child 
surviving  and  the  mother  dying. 

Moss^  and  Daunic  also  record  a  case  in  which  a  woman  suffered 
from  typhoid  fever  in  the  eighth  month  of  pregnancy.  At  birth 
the  blood  of  the  child,  the  blood  of  the  placenta,  and  the  milk  of 
the  mother  gave  the  Widal  reaction,  as  did  the  child  thirty- three 
days  after  birth. 

Another  interesting  illustration  of  the  fact  that  the  foetus  may 
become  infected  by  the  typhoid  bacillus  through  the  mother  is 
shown  by  a  case  reported  by  Eberth,^  of  a  woman  who  suffered 
from  typhoid  fever  in  the  fifth  month  of  pregnancy  and  miscar- 
ried, and  in  the  cardiac  and  splenic  blood  of  the  foetus  the  specific 
bacillus  was  found. 

Mosse  and  FraenkeP  have  made  a  report  upon  the  agglutination 
test  in  placental  blood  to  the  Societe  Medicale  des  Hopitaux,  in 
which  they  confirm  the  statements  already  made,  that  the  Widal 
test  can  be  obtained  from  the  placenta,  and  also  that  it  is  possible 
to  obtain  it  from  the  milk  of  the  mother  and  the  blood  of  the  foetus. 

Blumer*  reported  an  undoubted  case  of  congenital  typhoid  fever 
infection  in  which  the  mother  of  the  child  was  not  ill  with  the  dis- 
ease when  the  child  was  born,  but  had  passed  through  an  attack 
during  the  period  of  pregnancy.  Blumer  was  able  to  find  in  the 
literature  nine  similar  cases,  all  of  which  were  proved  by  blood 
culture. 

We  have  been  able  to  find  thirty-two  cases  of  congenital  typhoid 
fever  in  which  positive  cultures  were  found. 

These  cases  prove,  without  question,  that  the  typhoid  bacillus 
can  pass  from  the  mother  to  the  foetus  by  way  of  the  placenta,  a 
fact  proved  experimentally  by  Widal,  Frascani,^  and  Remlinger.*' 

1  Touvenaint.     Journal  de  Mddecine  de  Paris,  July  8,  1894. 

-  Eberth.     Centralblatt  f.   Bakteriologie  and  Parasitenkunde,   May   13,   1890. 

'  Moss^  and  Fraenkel.     Journal  des  Praticiens,  January  28,  1889. 

*  Blumer.     Journal  of  tlie  American  Medical  Association,  December  29,  1900. 

5  Frascani.     Rivista  Gen.  Ital.  di  clin.  Med.,  1892. 

"  Remlinger.     American  Journal  of  Obstetrics,  vol.  xxxix 


MOIililDITY   IN   r/U'X.'NANCV   AND  IN   /''(KTAf.   f. /!■'/■:        yj 

Thv  followiii^'  \'('i'\'  iiilcrcslin^  cmsc  in   (lii-,  cfjiiiKfiioii  li;is  hccti 
reported  to  us  by  1  )i-.  Wilirier  Kruscti : 

Mrs.  B.,  aged  twenty-seven  years,  a  native  of  Irchmd,  a  liousf;- 
wife  by  oeeuf)ati()n,  was  admitted  to  (he  liospitnl  l-'chniary  7, 
1899,  eiglit  nionllis  |)i-(-(;iiaii(.  I^'roni  licr  attcnrliiiL''  |)l)v^ifi;in  it 
was  learned  that  for  a  week  j)rior  to  licr  adinissitjn  she  had  had  a 
typical  typhoid  temperature  and  stools,  hut  no  spots.  On  admis- 
sion her  temperature  was  100,5°;  the  pulse  was  IGO;  respiration.s, 
24.  The  temperature  fell  steadily  until  it  reached  95°  at  10  a.m. 
on  February  8,  remaining  there  all  that  day;  the  pulse  ranging 
between  80  and  94,  and  the  respirations  between  18  and  '42. 
About  1  A.M.,  February  8,  she  developed  labor  pains,  which 
lasted  until  3  a.m.,  when  they  ceased  entirely;  the  pains  were 
never  severe,  and  labor  progressed  very  slowly.  The  temperature 
was  subnormal  all  the  time,  but  began  to  rise  toward  morning,  and 
reached  i99°  at  8  a.m.;  the  pulse,  100;  respirations,  36.  The  tem- 
perature continued  to  rise  slowly.  At  noon  on  February  9  very 
mild  labor  pains  again  began,  but  soon  ceased.  At  3  p.m.  the 
child's  head  had  descended  entirely  vidthout  any  pain  whatever. 
No  progress  being  made,  forceps  was  applied  and  the  child  delivererJ 
a  few  minutes  past  3  p.m.  Temperature,  100.4°;  pulse,  136;  respi- 
rations, 36.  Temperature  then  went  up,  and  at  6  p.m.  was  103.4°, 
and  continued  with  daily  remissions,  as  is  usual  in  typhoid.  A 
superficial  median  laceration  occurred;  it  was  sewed  up,  but  no 
healing  process  took  place,  and  the  stitches  had  to  be  removed. 
About  the  tenth  day  after  admission  the  temperature  became  very 
irregular,  ranging  from  97°  to  106.2°;  pulse,  from  110  to  150; 
respirations,  20  to  44.  The  vaginal  discharge  had  been  copious 
and  offensive,  and  continued  so  until  the  twenty-second  day  in  the 
hospital.  The  temperature  continued  to  be  irregular  throughout 
the  remainder  of  the  disease.  From  February  18  to  February 
24  the  temperature  became  reversed,  so  that  it  was  highest 
about  6  AM.  and  lowest  about  6  p.m.,  being  still  very  irregular. 
From  February  24  the  temperature  again  assmned  its  former 
character,  highest  in  the  evening  and  lowest  in  the  morning.  The 
vaginal  discharge  had  completely  stopped  by  February  28.  ha^^ng 
been  very  slight  for    the  preceding  tliree  or  four  days.     ^Nlarch  3 


38  GENERAL   CONSIDERATIONS 

the  temperature  was  *)S.4°  at  10  a.m.;  pulse,  92;  respirations,  24. 
The.  child  progressed  nicely.  The  Widal  reaction  was  taken 
March  2  with  a  very  high  dilution,  and  proved  to  be  negative,  though 
there  was  a  distinct  tendency  to  agglutination.  It  was  taken  again 
March  4  with  a  dilution  of  1  part  of  serum  to  about  25  parts  of 
water.     The  result  was  a  positive  reaction  in  eleven  minutes. 

A  somewhat  similar  case  has  also  been  recordetl  by  Batty  Shaw.^ 
A  woman  suffering  from  typhoid  fever  in  the  fifth  month  of  preg- 
naiuy  and  lier  child  gave  a  feeble  Widal  test  five  weeks  after  birth 
on  two  occasions,  but  on  two  other  occasions  the  test  was  negative. 

Two  cases  illustrating  typhoid  infection  during  the  last  weeks 
of  pregnancy  have  been  under  our  care,  having  been  transferred  to 
us  from  the  Jefferson  College  Maternity  AVards  by  Dr.  E.  P.  Davis. 
In  both  of  them  the  fever  began  practically  simultaneously  with 
parturition,  indicating  that  the  patient  had  become  infected  during 
the  last  two  weeks  of  pregnancy.  In  neither  one  of  them  were  the 
typhoid  manifestations  severe  so  far  as  nervous  and  circulatory 
symptoms  were  concerned,  but  in  one  the  temperature  was  fairly 
high  and  persistent.  The  blood  of  the  children  did  not  give  the 
Widal  test. 

Mortality  and  Morbidity  in  Later  Life. — In  patients  over  forty 
years  of  age,  typhoid  fever  is  a  rare  but  grave  disease,  the  mortality 
increasing  with  the  years.  The  fever,  as  already  indicated,  is  apt 
to  be  mild,  but  death  comes  more  commonly  than  in  comparative 
youth  from  complications  such  as  pneumonia  and  heart  lesions 
(Fig.  8). 

Dreschfekl  has  reported  a  case  of  typical  typhoid  fever  in  a 
man  of  seventy-five  years,  and  another  in  a  man  of  eighty-two 
years.     In  the  latter  case  he  states  that  recovery  took  place. 

Morris  Manges^  has  called  attention  to  the  fact  that  the  immunity 
of  those  of  advanced  age  is  less  than  was  generally  supposed,  and 
he  reports  five  patients  over  sixty  years  of  age  who  had  typical 
attacks  of  typhoid  fever,  while  Hamilton''  has  drawn  further  atten- 
tion to  the  subject  by  reporting  an  epidemic  of  the  flisease  in  the 


'  Batty  Sliaw.     Ivondon  Lancet,  1897,  vol.  ii,  ij.  539. 

2  Manges.     Medical  Record,  February  26,   1898. 

^  Hamilton.     American  Journal  of  the  Medical  Sciences,  October,  1907. 


MOHTALITY    AND   MOh'i:/ h/'f)     /.V    LATI''.!!   /.//■/■:  \>,\) 

lK)S|)i(;il  lor  tlie  insane  at  In(lc|)<ii(|<n(c,  loun,  in  uliich  27  patients 
over  fil'ly  years  of  aj^e  were  att.uked.     'IMie  a^es  were  jus  follf)Ws: 

YearH.  f'ajM.-H. 

60  to  54 r; 

5.')  to  .TO S 

(iO  to  (14 !) 

05  to  (19 ) 

70  to  74 2 

75  to  79 1 

'J'lie  mortality  was  22.22  per  cenl  in  this  series. 

Fir;.    8 


AGE 

10 

II-IC 

ii;-20 

21-2.7 

i'i;-.'iu 

?A-X, 

■■v,-w 

u-i.: 

'---" 

.-.i-.:mj 

y,-'A) 

1.1 

PERCENT 
50 

40 

30 

20 

10 
0 

- 

/■ 

' 

; 

/ 

/ 

!  / 

1/ 

1 

/ 

' 

> 

/ 

} 

A 

k 

^ 

/ 

V 

s 

y 

/ 

•s 

V 

y 

/ 

y' 

__ 

j^ 

^ 

^ 

'' 



1 

/ 

/ 

1 

/ 

_ 

Chart  showing  the  increasing  mortality  of  typhoid  with  advancing  years.     (Curschmann.) 

Osier  states  that  of  829  cases  of  typhoid  fever  treated  at  the 
Johns  Hopkins  Hospital,  there  were  6  between  fifty  and  sixty  years 
of  age  and  6  between  sixty  and  seventy.  Two  of  these  cases  were 
not  recognized  during  life.  In  the  New  York  Board  of  Health 
report,  of  a  total  of  3634  deaths  due  to  typhoid  fever,  from  1S87 
to  1S96,  there  were  9o  deaths  in  persons  over  sixty-five  and  414 
between  fortv-five  antl  sixtv-five  vears. 


40  GENERAL  CONSIDERATIONS 

Short  Incubation. — While  it  is  generally  true  thcat  the  period 
of  incubation  of  t>phoitl  fever  extends  over  a  period  from  ten  days 
to  two  weeks,  recent  reports  indicate  that  in  certain  instances  this 
period  may  cover  only  a  few  days.  Thus,  Janehen-Graz^  has 
reported  thirty-six  cases  of  typhoid  fever  occurring  among  soldiers, 
in  whom  definite  proof  was  adduced  that  they  had  all  become 
infected  at  the  same  time  by  drinking  infected  water.  As  a  result 
the  incubation  period  in  three  cases  was  only  two  days,  in  seven 
cases  three  days,  in  six  cases  four  days,  and  in  thirteen  cases  five 
to  seven  days. 

Two  unusual  opportunities  for  studying  the  incubation  period 
of  this  disease  have  been  recorded  by  Voisin.^  The  first  case  was 
that  of  a  girl  aged  nineteen  years,  who  swallowed  a  virulent  culture 
of  typhoid  bacilli  vdth  suicidal  intent.  On  the  third  day  after  the 
germs  were  swallowed  the  patient  began  to  complain  of  headache, 
the  next  day  a  slight  temperature  developed.  For  two  days  head- 
ache and  temperature  continued  and  there  was  malaise  and  general 
discomfort;  on  the  seventh  day  abdominal  pain  developed.  On  the 
eighth  day  she  was  worse,  and  had  a  few  rose  spots.  There  was 
marked  depression  on  the  ninth  day,  tongue  dry  and  coated,  and 
there  was  pain  in  the  right  iliac  fossae.  The  spleen  was  enlarged 
and  the  Widal  reaction  positive  1  to  15,  but  negative  1  to  50.  The 
course  of  the  fever  was  a  typical  one,  and  the  patient  recovered. 

In  the  second  case,^  a  young  Russian  physician  accidentally 
infected  himself  with  typhoid  bacilli  by  aspirating  a  small  amount 
of  a  bouillon  culture  into  his  mouth  while  making  a  Widal  test. 
He  immediately  rinsed  his  mouth  with  bichloride  solution,  but 
typical  typhoid  fever  developed.  The  first  symptom  appeared 
upon  the  fifth  day  and  rose  spots  and  a  splenic  tumor  could  be 
determined  upon  the  thirteenth  day. 

'  Janelien-Graz.     Miinchener  medicinische  Wochenschnft,  1898,  p.  936. 
2  Dufloeq  and  Voisin.     Archiv.  G^n<?rale  de  M^decine,  September  1,  1903. 
^  Semaine  Mddioale.  January,  1905. 


CHAPTER    TT. 

VARIETIES  OF  ()NSP:T. 

Before  attempting  to  consider  the  variations  whieh  take  place 
in  the  stage  of  onset  in  typhoid  fever,  it  is  necessary  to  have  some 
standard  type  of  an  average  case  of  the  disease  in  this  period. 
The  usual  mode  of  onset,  as  descrihcd  l)y  Dresdifcld  in  Allltutt's 
System  of  Medicine,  is  as  follows: 

'Tn  many  ordinary  cases  the  onset  is  insich'ons.  'J'hc  patient 
complains  of  pain  in  the  limbs,  of  excessive  fatigue,  of  cold  and 
chilly  sensations,  of  headache  often  very  severe,  of  loss  of  appe- 
tite, and  of  sleeplessness.  Epistaxis  is  a  very  common  symptom, 
and  generally  occurs  about  the  second  or  third  day  of  the  disease. 
These  symptoms  become  more  severe,  the  patient  has  to  take  to 
his  bed,  and  from  this  day  we  generally  reckon  the  duration  of 
the  fever.  In  many  cases,  however,  as  shown  by  the  changes  after 
death,  the  beginning  of  the  morbid  process  must  be  dated  from 
the  very  first  symptom.  The  tongue  becomes  furred,  and  is  at 
first  moist;  there  is  a  steady  rise  of  temperature,  the  evening 
temperature  being  generally  H°  higher  than  the  morning  tem- 
perature, so  that  about  the  fourth  day  the  temperature  reaches 
103°  or  104°;  the  pulse  rises  to  90  or  100,  rarely  higlier  except 
in  very  severe  cases,  or  in  very  young  or  debilitated  subjects,  is 
dicrotic  and  indicative  of  low  blood  pressure;  ther*^  is  increased 
thirst;  the  abdomen  is  slightly  distended  and  tencL^r  on  pressure; 
diarrhoea  may  as  yet  be  absent,  and  there  ma\  Le  constipation, 
or  there  may  be  two  or  three  fluid  stools  from  the  first.  Beyond 
headache,  which  persists  for  a  few  days,  and  sleeplessness,  there 
are  as  yet  no  other  symptoms;  the  skin  is  dry,  but  there  are 
paroxysms  of  profuse  perspiration.  The  spleen  is  as  yet  but 
little  enlarged,  and  there  are  as  yet  no  roseolar  spots,  though 
when  perspiration   is   profuse,    sudauiina   are  noticed;    the  urine 


42  var/i-:ties  of  onset 

has  febrile  characters,  and  as  yet  does  not  show  the  diazo  reaction. 
This  stage  hists  about  seven  (hiys,  and  constitutes  tlie  first  week 
of  the  enteric  fever." 

If  this  be  taken  as  a  type  of  an  average  case,  we  find  at  once  that 
on  either  side  of  this  type  undoubted  cases  occur  wliich  by  their 
extreme  mildness  may  be  overlooketl,  or  by  their  great  severity  may 
mislead  the  physician  into  the  diagnosis  of  some  more  acute  and 
rapidly  progressing  affection.  In  the  mildest  of  these  cases  there 
is  little  to  be  found  indicative  of  enteric  fever  save,  as  Lieber- 
melster  puts  it:  "The  long  duration  of  an  apparently  trifling  indis- 
position in  which  the  patient  presents  a  general  impairment  of 
health,  malaise,  physical  and  mental  depression,  and  headache, 
with  loss  of  appetite,  the  tongue  being  coated,  and  the  pulse  often 
distinctly  slower  than  normal."  No  fever  may  be  present.  So 
moderate  may  all  the  symptoms  be  that  a  differential  diagnosis 
between  subacute  gastro-intestinal  catarrh  and  mild  typhoid  fever 
may  be  practically  impossible  except  by  the  aid  of  Widal's  test, 
which  rarely  gives  results  so  early  as  the  days  of  onset.  Certain 
of  the  German  writers  have  gone  so  far  as  to  assert  that  all  cases 
of  subacute  catarrh  of  this  character  depend  for  their  existence 
upon  mild  typhoid  infection. 

Not  only  may  the  course  of  the  malady  be  very  mild  indeed, 
but  it  may  be  so  brief  as  to  throw  doubt  on  its  specific  character, 
the  whole  illness  lasting  twelve  to  seventeen  days,  and  then  recovery 
being  established.  Sometimes  even  less  time  elapses  before  the 
fever  ceases  and  the  patient  is  manifestly  convalescing. 

Then,  again,  the  abortive  type  of  this  fever  presents  itself,  in 
which,  after  an  illness  beginning  with  quite  characteristic  mani- 
festations, often  of  considerable  severity,  the  symptoms  rapidly 
ameliorate,  and  convalescence  is  established  within  ten  days  of  the 
onset.  This  is  well  illustrated  by  the  temperature-chart  (Fig.  9) 
of  a  student  under  our  care.  On  March  S  he  first  began  to  suffer 
from  symptoms  which  were  severe  enough  to  make  him  seek 
medical  aid  and  go  to  bed.  Prior  to  this  date  he  had  felt  but 
slightly  unwell  and  this  only  for  a  few  days.  As  is  seen  in  the  chart, 
his  temperature  fell  by  crisis  on  the  seventh  day  of  his  illness, 
although  the  positive  Widal  reaction  indorsed  the  diagnosis  of  true 


VMiiHi'ii'is  oi'  os'si-rr 


43 


iyplioid  t'cvcr.  ( 'iirioiish'  cnoii^li,  -.imIi  cii  ,c,  ;iic  ot'tcn  ii  lir-ifd  in 
suddenly  by  nuirkcd  sinus  liiirli  fever  jind  indications  ui  ^nivcr 
illness — and  yet  so  speedily  pass  on  lo  die  fall  Ky  lysis  dial  if  secnxs 
as  if  the  attack  niusi  Ix-  ilnc  to  some  oilier  inl'eetjon.  Sneh  ea,ses 
are  recorded  in  wliicli  an  initial  fever  of  lOii^^  in  the  axilla  has  her-n 
followed  l)V  a  normal  leinneralni'c  as  earl\'  as  the  se\-etitli  dav. 


1-|<:.   !) 


F.     104° 
103° 

102° 
101° 
100° 
99^^ 
98° 
97° 

Day  of  Dis. 

- 

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■" 

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Abortive  typlioid  fever  ending  by  tlie  seventli   day.  and   by  crisis  instead  of  lysis. 

In  the  mahgnant  forms  of  infection,  the  symptoms  of  onset  may 
be  of  three  types,  viz.,  mild,  followed  by  symptoms  of  increasing 
severity;  severe,  with  rapidly  fatal  developments;  and,  finally, 
aberrant  symptoms  pointing  rather  to  the  cranial  contents,  tho- 
racic organs,  or  other  parts  of  the  body  than  to  the  abdominal 
contents.  These  various  types  will  be  found  fully  discussed  in  the 
following  pages,  but  as  an  illustration  of  the  cerebral  type,  a  case 
reported  by  Green^  may  be  cited.  A  child,  aged  four  years,  had 
been  quite  well  until  four  days  before  admission,  when  he  was 
seized  with  an  attack  of  giddiness  while  pla\-ing.  turned  around 


1  Green.     Australian  Medical  Gazette  for  August  29.  1S97. 


44  VARIETIES  OF  ONSET 

and  aroiiml,  and  fell;  but  there  was  no  loss  of  consciousness  and 
no  convulsive  movements.  Two  hours  later  he  vomited.  There 
was  no  ear  trouble.  A  week  later,  the  seventh  day  of  the  attack, 
the  child  had  a  convulsion,  lasting  two  minutes,  which  affected 
both  sides  of  the  body,  and  again  on  the  eleventh  day  of  his  illness 
he  had  a  verv  severe  convulsion,  lasting  two  hours,  affectino;  both 
sides,  although  after  it  passed  off  there  was  marked  twitching  of  the 
right  side  and  conjugate  deviation  of  the  eyes  to  the  right.  The 
next  day  hemiplegia  affecting  the  right  side  was  w^ell  developed. 
The  convulsions  proceeded  oft'  and  one  for  two  days,  aftecting  only 
the  right  side.  Afterward  vomiting  became  a  constant  symptom, 
and  death  occurred  on  the  thirtieth  day  of  illness  and  nineteen  days 
after  the  first  severe  convulsion.  At  the  autopsy  a  large  portion 
of  the  temporosphenoidal  lobe  of  the  left  side  was  discovered  to 
be  quite  soft  and  pulpy,  and  on  making  a  transverse  section  of  this 
area  the  softening  was  found  to  affect  the  lenticular  nucleus  and  to 
abut  very  closely  to  the  anterior  horn  of  the  internal  capsule.  There 
was  no  hemorrhage,  but  the  left  middle  cerebral  artery  was  filled 
with  a  blood-clot. 

^'N^ien  it  is  possible  for  a  disease  to  present  such  widely  various 
symptoms  as  have  just  been  detailed,  in  its  early  stages,  and 
when  w^e  are  told  by  Liebermeister  that  "there  is  not  a  single 
symptom  belonging  to  typhoid  fever  that  is  pathognomonic,"  it 
is  evident  that  errors  in  diagnosis  must  occur  even  in  the  most 
skilful  hands. 

Temperature  Variations  from  the  Usual  in  Onset. — Leaving 
the  general  consideration  of  the  types  of  onset  for  a  discussion 
of  the  individual  symptoms  of  this  period,  we  may  take  up  the 
question  of  the  range  of  temperature.  The  normal  variation  or 
character  of  the  fever  of  onset  has  already  been  described  in  the 
preceding  pages,  but  marked  variations  from  that  course  are  often 
present. 

In  this  connection,  Dreschfeld  quotes  with  approval  a  state- 
ment of  Wunderlich's,  which  seems  to  the  writers  entirely  too 
dogmatic,  in  regard  to  the  character  of  the  oncoming  fever,  and  it 
is  certainly  entirely  at  variance  with  more  recent  observations.  We 
quote  it  to  illustrate  the  older  view  of  the  disease:  "Any  fever 


TEMFEI{.ATiJIU<:  Vy\UIATI()NS  l<'ia)M  Till':  USUAL   IN  OSSLT      /).', 

which  on  the  second  day  njadies  to  10  K'  is  not  culciif  lever,  nor 
is  it  enteric  if  tlic  fever  does  not  jipprrijieh  10  1'  on  the  evening  of 
the  fourth  (liiy;  on  the  olliec  himd,  enlerie  fever  ni;iy  he  (h'agno.s- 
ticated  if  in  a  niiddl('-;i<i;ed  j)erson  snll'ei-in;^  from  ;in  iienle  f'ehrile 
attack  the  evening  temperature  on  the  fifth  day,  oi-  widiin  die  hi  ^t 
week,  is  between  103°  and  105°,  anc]  alternates  widi  morning  tem- 
peratures, which  are  1.4°  to  1.7°  h>wer,  unless  some  other  (h'soiihr 
can  he  discovered  to  explain  the  height  of  the  fever.  Jt  is  \\<'ll 
to  state  that  by  morning  temperature  we  mean  the  t(;mperature 
about  9  A.M.;  by  evening  temperatiu'c,  lh;i(  .-ihonl  i»  i-.m."  The.se 
views  certainly  do  not  hold  true  today  for  tlie  ordinary  types  of 
the  disease.  Attention  has  already  been  called  to  the  very  low 
temperature  seen  in  the  mild  forms  of  the  disease  amJ  to  the  high 
fever  sometimes  met  with  even  in  the  so-called  abortive  cases. 

Diu'ing  the  stage  of  onset  variations  in  the  temperature  of  the 
patient  may  be  due  to  complicating  states  which  are  about  to  be 
described,  or  they  are  perversions  of  the  ordinary  temperatui-e  of 
the  initial  days,  occurring  without  assignable  cause.  The  presence 
of  a  consolidation  in  the  lung,  of  a  pleurisy,  or  of  a  serious  lesion 
in  any  one  of  the  organs  of  the  body,  may  entirely  alter  the  chart 
in  this  period  of  the  malady;  and  predominant  localized  symptoms 
may  still  further  mask  the  case. 

Tliis  is  well  shown  by  the  following  case  recorded  h\  ^lovvis} 
Aside  from  its  obscure  mode  of  onset,  this  case  is  also  of  interest, 
since,  as  a  rule,  gall-bladder  infection  manifests  itself  after  an 
attack  of  typhoid  fever  rather  than  before : 

On  September  21,  1898,  he  was  called  in  consultation  by  Dr.  R. 
E.  Doran,  of  Willard  State  Hospital,  to  see  ]\L-.  J.  L.  B.,  twenty- 
six  years  of  age,  who  had  been  suddenly  seized  forty-eiglit  hours 
previously,  with  a  sharp  pain  below  the  right  inferior  costal  mar- 
gins, which  rapidly  extended  as  an  acute  general  peritonitis,  with 
a  temperature  reacliing  102°,  but  apparently  without  accom- 
panying rigors.  The  patient  was  constipated  until  the  day  on 
wliich  Dr.  INIorris  arrived.  On  examination  a  mass  was  easily 
palpated  at  the  site  of  the  gall-bladder,  and  the  peritonitis  seemed 

1  Morris.     New  York  Medical  Journal,  Januarj-  2S,  1S99. 


46  VARIETIES  OF  ONSET 

to  be  most  intense  at  that  point.  They  diagnosticated  empyema 
of  the  gall-l)hulder  and  operated.  The  peritonenm  was  deeply 
congested  and  was  covered  with  coagnhUed  lynij)h  in  the  vicinity 
of  the  oall-hhulder.  The  i>all-l)hid(ler  was  (h'stended  with  a  mix- 
ture  of  thin,  greenisli  mncns  and  thick,  tenacions  yeUow  pus.  Dr. 
Morris  did  not  have  his  culture-tubes  at  hand,  and  no  bacterio- 
logical examination  of  the  pus  was  obtained,  much  to  his  regret. 
He  drained  the  wound  and  the  gall-bladder  with  a  small  wick 
drain  and  closed  the  incision,  excepting  for  the  drainage  opening. 
On  the  evening  of  the  day  of  operation  the  temperature  rose  to 
103°  and  dropped  on  the  following  morning  to  100°;  the  pulse 
to  88;  the  respirations  to  24.  On  the  evening  of  the  second  day 
after  operation  the  temperature  rose  to  106°.  Up  to  tliis  time 
the  l)owels  had  not  moved,  but  two  high  enemata  of  Epsom  salt 
caused  a  number  of  loose  movements,  and  the  symptoms  of  dan- 
gerously progressive  infection  subsided  rapidly.  After  this  the 
symptoms  of  typhoid  fever  supervened,  and  the  case  ran  a  typical 
course  as  one  of  typhoid  fever,  ending  in  recovery  in  about 
four  weeks,  excepting  for  a  small  biliary  fistula,  which  closed 
spontaneously. 

In  nervous  cliildren  or  women  the  irritation  of  the  heat  centres 
often  results  in  a  sudden  rise  like  that  which  is  met  with  in  the 
more  acute  maladies  of  an  infectious  type.  And  it  is  a  well-known 
fact  that  typhoid  fever  in  children  is  more  apt  to  be  ushered  in  by 
a  chill  and  high  fever  than  it  is  in  adults,  as  has  been  well  pointed 
out  by  Jacobi  and  J.  Lewis  Smith.  A  case  of  this  character  is 
reported  by  (niinon,^  in  which  a  child  of  two  and  one-half  years 
was  seized  with  high  fever  and  with  all  the  symptoms  of  pernicious 
malarial  infection.  Nine  days  later  it  suffered  from  collapse  with 
all  its  characteristic  symptoms,  and  the  day  following  passed  stools 
wdiich  were  typhoid  in  appearance.  Collapse  again  occurred,  and 
on  the  twelfth  day  symptoms  of  meningitis  developed.  Finally,  a 
rose  rash  appeared,  the  spleen  and  liver  were  found  to  be  enlarged, 
and  the  case  proved  itself  to  be  one  of  immistakable  typhoid  fever. 
The  early  age  of  the  chikl,  the  sudden  onset,  the  flushed  face,  the 

i  Guinon.     Revue  Mensuelle  des  Maladies  I'Enfaiice,  1897,  p    23(1. 


TFMI'l<:RATUIil<:  \AU/ATI(K\S  hIidM  Tlir:  I  SIM.  I .\  OSSI/I'      17 

lii^'li  fVvcr,  (lie  colljipsc,  iiiid,  (iii;illv,  llic  inciiiiiof'jil  symptom-   ;ii<- 
of  interest. 

Ill  some  instances  in  wliicli  lii;^!!  ninpcniluiv-  i-:  nolcil  when 
tlie  ])liysici;ui  first  sees  the  j);itienl,  it  is  not  in  re;ility  llie  earlifst 
perversion  of  norniiil  (emperalure  in  tlial  ;i  mild  :\\u\  nnnrdieefj 
fever  lias  been  |)rescn(  for  some  days,  even  iIioumIi  die  pnticnl  lias 
felt  perfectly  well. 

Hi^h  initial  teniperatnres  should  place  die  j>liy>ici;iii  on  hi.-> 
guard,  heciuise  they  may  mean  severe  infection  or  srjme  ^rave 
complication  which  he  must  search  for  and  ijiscovcr,  and  partic- 
ularly is  this  the  case  if  the  initial  temperature  is  ushered  in  or 
is  followed  by  a  chill  or  ri<^or.  In  some  of  these  ca.ses  careful 
study  of  the  history  of  the  patient  \\\\\  reveal  an  exposure  to  malarial 
infection,  and  an  examination  of  the  blood  may  reveal  the  presence 
of  the  malarial  parasite,  although,  as  pointefl  out  farther  on,  this 
organism  is  apt  to  be  absent  from  the  blood  during  the  active 
period  of  typhoid  fever. 

The  more  sudden  the  appearance  of  the  disease,  and  the  more 
rapid  the  rise  of  temperature  in  the  beginning  of  the  first  week,  so 
much  the  more  should  one  expect  in  general  a  short  and  even 
abortive  attack,  and  the  more  rapidly  the  temperatiu-e  falls,  as 
the  end  of  the  first  week  is  approached,  the  l)etter  the  prognosis, 
particularly  if  the  daily  fluctuations  are  marked. 

Very  sudden  development  of  true  hyperpyrexia  at  this  stage, 
unless  it  is  due  to  some  severe  complication,  is  very  rare. 

Chills. — In  some  instances,  not  commonly  met  with,  typhoid 
fever  uncomplicated  by  other  states  is  ushered  in  by  severe  chills. 
As  already  pointed  out,  these  are  most  apt  to  appear  in  children, 
and  they  may  indicate  the  development  of  some  coincident  infection. 
Chills  may,  however,  be  due  to  the  typhoid  infection  itself.  They 
are  met  with  more  frequently  at  the  onset  of  a  relapse  than  at  the 
primary  onset.  In  a  case  under  our  care,  a  man  of  thirty-five 
years,  after  several  days  of  malaise,  without  fever,  was  seized  with 
a  violent  rigor  and  at  once  became  so  ill  that  he  was  forced  to  go 
to  bed,  where  he  passed  through  a  severe  attack  of  the  disease. 

Osier,  in  his  consideration  of  chills  in  typhoid  fever,  diAides  them 
into  six  classes.     (1)  Where  the  chills  occur  at  the  onset  of  the 


48  VARIETIES  OF  ONSET 

disease;  (2)  at  the  onset  of  the  relapse;  (3)  as  aresuU  of  treatment; 
(4)  ^^^th  the  onset  of  comphcations;  (5)  septic  chills  during  con- 
valescence in  protracted  cases;  and  (6)  chills  due  to  concurrent 
malaria.  In  the  series  of  829  cases  reported  by  Osier,  chilly  sensa- 
tions were  noted  during  the  prodromal  period  in  213  instances. 

Under  the  name  of  "sudoral  typhoid  fever,"  Jaccoud  recorded 
in  La  Semaine  Mcdicale  for  March  12,  1897,  his  belief  in  this 
special  type,  in  which  cliills  and  sweats  are  prominent  symp- 
toms. The  onset  of  the  malady  is  sudden,  and  is  accompanied 
by  severe  headache  in  the  retroorbital  and  occipital  regions 
with  shivering,  fever,  and  sweats,  so  that  the  patient  resembles 
one  suffering  from  an  intermittent  malarial  attack.  These  attacks 
are  often  quotidian,  and  the  febrile  movement  is  hyperpyretic. 
The  peculiar  symptoms  cease  by  the  fifth  day,  and  are  followed 
by  the  usual  course  of  typhoid  fever.  Quinine  does  no  good  in 
these  cases,  and  they  are  not  due  to  malarial  infection.  A  second 
form  is  characterized  by  the  primary  appearance  of  headache 
and  fever  followed  by  sweating,  which  is  profuse  and  asserts 
itself  much  later  than  in  the  form  just  described.  The  febrile 
movement  is  distinctly  intermittent  in  type,  but  not  so  markedly 
so  as  in  the  form  just  named.  In  other  cases,  in  place  of  a  marked 
rigor,  the  patient  has  a  subjective  sensation  of  coldness  in  some 
part  of  the  body,  which  can  also  be  perceived  by  the  physician  if 
he  touches  the  spot.  In  these  forms  the  irregular  manifestations 
may  last  three  weeks  and  then  gradually  cease  in  the  fourth  week. 
Sometimes  these  cases  are,  however,  very  prolonged,  and  Borelli 
has  reported  instances  lasting  seventy  or  ninety  days.  Indeed, 
Jaccoud  regards  the  length  of  the  attack  as  characteristic.  There 
are  practically  no  complications.  Albuminuria  is  extremely  rare, 
but  intestinal  hemorrhage  of  mild  degree  is  not  uncommon.  Peri- 
tonitis  from  perforation,  Jaccoud  asserts,  is  quite  unknown  in  these 
forms,  and  he  regards  "sudoral  typhoid  fever"  as  a  mild  type  of 
the  disease.  Notwithstanding  the  close  resemblance  of  these  types 
to  double  infection  by  the  malarial  organism  and  the  typhoid 
bacillus,  both  Jaccoud  and  Borelli  believe  them  to  be  pure  typhoid 
fever,  because  they  occur  in  persons  who  have  never  been  exposed 
to  malarial  infection,  and  because  quinine  is  useless. 


TEMPEHATUJiJ'J  V  A  HI  AT  IONS  FliOM  'I'll  I;   CSUAL  IS  OSSHT      \[) 

The  differcntiiil  diiif^nosis  is  iicc'cs.sfirjly  (Jifliculi  in  idc  c;!!!-.- 
stages  of  the  disease,  although  in  general  Jaceoiid  would  have  us 
beheve  that  it  is  easy.  It  must  (Jepeiid  hirgely  upon  the  aljsenee 
of  any  history  of  ninhnijd  exj)()sin(',  upon  complete  d<-vcK)pnifnt 
of  most  of  the  characteristic  signs  of  typhoid  fever,  and,  fin;dly, 
upon  the  al)sence  of  any  signs  of  tlie  niidMri;d  organism  in  the 
blood  and  the  presence  of  the  Widal  reaction.  In  cases  of  "abor- 
tive sudoral  typhoid  fever,"  in  which  the  disease  runs  a  very  short 
course  and  stops  abruptly,  the  diagnf)sis  is  very  flifficult.  Jacr-oud 
describes  such  a  case  as  follows: 

"In  the  patient  referred  to,  the  headache  and  the  temperature 
chart  justified  the  diagnosis  of  mild  typhoid  fever,  but  the  diges- 
tive organs  were  intact;  there  was  no  abdominal  tympanism  and 
no  diarrhoea.  The  spleen  was  of  perfectly  normal  size,  the  tongue 
a  little  dry,  but  otherwise  showed  absolutely  none  of  the  charac- 
teristics of  typhoid  fever.  There  was  absolutely  nothing  in  the 
limgs.  The  fever  alone,  and  the  slightly  stupefied  appearance  of 
the  patient,  led  us  to  assume  the  existence  of  some  typhoid  infec- 
tion. There  also  existed  on  his  body  a  measly  eruption;  but  this 
was  a  superadded  element,  due  probably  to  the  large  doses  of  anti- 
pyrine  which  he  had  taken,  and  also  to  some  alcoholic  frictions, 
which  had  been  given.  Besides,  he  was  a  grocer  by  trade,  and 
grocers  are  specially  exposed  to  skin  irritations  which  not  infre- 
quently give  rise  to  cutaneous  affections.  On  the  first  days  he 
had  presented  a  certain  degree  of  ocular  catarrh,  with  redness  of 
the  conjunctiva  and  watery  eyes.  Then  abundant  perspiration 
appeared  on  the  forehead,  the  nose,  and  the  chest,  drenching  those 
parts  completely.  The  fever  developed  in  this  way  for  ten  days, 
the  headache  was  general  and  persistent,  but  not  very  intense,  and 
during  the  whole  of  this  time  there  was  nothing  worthy  of  note, 
except  the  hypersudation  and  the  rubeolar  eruption. 

"The  case  was  evidently  one  of  abortive  typhoid  fever  of  the 
sudoral  variety,  and  could  be  classed  in  the  mixed  form  wliich  I 
have  described.  There  was  one  abnormal  point,  viz.,  the  subsi- 
dence of  the  fever,  wliich  was  complete  on  the  tenth  day.  Such 
rapid  termination,  not  very  unusual  in  ordinary  t%-phoid  fever,  is, 
I  repeat,  almost  exceptional  in  sudoral  typhoid.  The  differential 
4 


50  VAIUETJES  OF  ONSET 

diagnosis  between  sndoral  typhoid  and  malaria,  i.  e.,  typhonialaria, 
is,  on  the  whole,  easy,  and  hesitation  between  the  two  cannot  last 
long,  the  administration  of  quinine  salts,  which  are  without  action 
on  sudoral  typhoid,  setdes  the  question." 

The  violent  headache  of  so-called  sudoral  typhoid  fever,  which 
is  sometimes  the  only  ])rodrome,  may  lead  one  to  think  of  influ- 
enza, and  in  particular  of  tlic  nervous  form  of  that  disease;  but 
in  influenza  the  pain  is  not  localized  in  the  head  alone.  It  ap- 
pears early  and  is  very  intense,  but  is  also  general  all  over  the 
body;  the  temperature  may  remain  normal,  or,  if  there  is  fever, 
the  temperature-curve  is  totally  different  from  that  of  tyj)hoid 
fever.  The  evolution  of  the  influenza  itself,  which  is  in  general  of 
short  dm'ation  when  it  remains  uncomplicated,  helps  considerably 
in  the  differential  diagnosis. 

One  might  be  misled  into  diagnosticating  measles  when,  along 
with  the  ocular  catarrh,  there  is  a  discrete  eruption  of  rose-colored 
spots,  or  else  a  true  roseolar  eruption  like  that  of  the  patient 
under  consideration.  The  absence,  however,  of  all  eruption  on 
the  face  and  neck  and  of  severe  bronchopulmonary  catarrh,  the 
insignificance  of  the  ocular  catarrh,  and  the  character  of  the  tem- 
perature-chart, all  enable  us,  Jaccoud  thinks,  to  eliminate  this 
disease  without  much  difficulty. 

The  senior  author  had  under  liis  care  during  the  winter,  1898-99, 
a  case  which  followed  this  com'se: 

A  man  of  twenty-five  years,  a  cigarmaker  by  occupation,  was 
taken  ill  with  what  was  supposed  to  be  ''malaria"  or  "la  grippe" 
on  February  4,  but  felt  better  and  returned  to  work  on  the  6th. 
On  the  7th  he  felt  very  ill,  and  entered  the  wards  on  the  8th. 
At  this  time  he  had  marked  swelling,  as  if  from  a  phlebitis,  of  the 
left  leg,  which  entirely  disappeared  in  twenty-four  hours.  He 
presented  all  the  characteristic  symptoms  of  ordinary  typhoid 
fever  by  the  tenth  day  of  the  disease,  but  his  temperature  made 
the  folloA\ang  extraordinary  chart,  each  rise  being  followed  by 
profuse  sweating.  He  also  had  profuse  night-sweats.  He  never 
had  typhoid  fever  before,  nor  were  there  any  signs  of  tuberculosis 
or  ulcerative  endocarditis.  His  blood  showed  no  signs  of  the 
malarial  organism  and  gave  the  Widal  reaction  on  the  thirteenth  day. 


UNSI'lllATOUY   CON  1)11' IONS  IN   ONSHT 


51 


It  is  of  interest  to  iiolc  llinl  diifinn-  ihc  icn  years  since  the  first 
edition  of  tin's  work  appciircd  di<-i('  liiivc  jippf.-ircrl  in  fiie  French 
ine(h'("i,l    journals   oecitsional    accoinil.s  of    (liis   so-called    "sudoral 


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To  save  space,  this  chart,  wliich  showed  in  detail  rigor  after  rigor  and  fever  after  fever, 
has  been  reduced  to  a  morning  and  evening  chart,  and,  therefore,  only  shows  two  or  three 
paroxysms. 

typhoid  fever."  In  America  many  of  these  cases  are  really 
instances  of  obscure  tuberculous  infection.  Very  rarely  these 
patients  have  not  given  either  positive  tests  with  tuberculin  or 
with  the  Widal  reaction. 

(For  a  discussion  of  so-called  typhomalarial  fever  and  of  malaria 
complicating  typhoid  fever,  see  chapter  on  the  fever  in  the  well- 
developed  stage  of  the  disease,  and  that  on  other  diseases  w^hich 
resemble  typhoid  fever.) 

Respiratory  Conditions  in  Onset. — Several  cases  have  im- 
pressed upon  us  the  fact  that  so-called  "pneumotyphoid  fever"  is 


52  VARIETIES  OF  ONSET 

a  more  common  state  than  is  generally  thought,  although  it  is  true 
that  the  standard  text-books  all  describe  this  form  of  the  disease. 
By  pneunioty})hoid  fever  we  refer  to  that  form  of  typhoid  fever 
in  which  the  bacillus  of  Eberth  exercises  its  primary  influence 
upon  the  pulmonary  parenchyma,  producing  signs  and  symptoms 
which  are  practically  identical  with  those  of  ordinary  croupous 
pneumonia,  even  to  the  rusty  sputum,  although  the  usual  rigor  of 
onset,  as  seen  in  true  croupous  pneumonia  may  be  absent  or  modi- 
fied, and  the  onset  in  general  is  more  insidious.  In  these  cases 
toward  the  ninth  or  tenth  day  the  high  fever  falls  but  slightly  in 
place  of  the  characteristic  crisis,  and  when  diarrhoea  and  rose  spots 
appear,  the  possibility  of  the  entire  illness  being  due  to  a  typhoid 
infection  comes  upon  the  mind  of  even  the  careful  physician  for 
the  first  time.  This  condition  must  not  be  confused  with  the  so- 
called  typhoid  pneumonia,  in  wliich  there  is  a  double  infection  of 
the  patient,  his  lung  bearing  the  chief  influence  of  the  ])neimiococcus 
and  his  intestinal  canal  and  general  system  that  of  the  bacillus  of 
Eberth,  nor  the  state  in  which  the  pulmonary  consolidation  results 
from  asthenia  or  other  causes  incidental  to  the  progress  of  an 
exhausting  malady,  and  which  is  usually  a  catarrhal  ]:)neumonia 
or  a  conjrestion  bv  stasis.  As  Osier  has  well  said,  "tvi)lu)id  fever 
is  a  multiple  infection  in  which  the  cliief  lesion  of  the  disease  may 
be  found  in  other  organs  than  the  bowels,"  and,  in  a  larger  ninnber 
of  cases  than  is  thought,  pneumonia  begins  the  attack  of  illness,  and 
only  later  on  does  the  character  of  the  specific  infection  make  itself 
manifest.  The  following  case  illustrates  this  fact  very  well,  and  is 
one  of  a  number  which  have  been  met  with  by  the  senior  author: 
Z.,  a  girl,  aged  ten  years,  was  taken  ill  with  a  rigor  and  fever  on 
November  10,  having  been  well  enough  to  be  up  and  out  of  doors 
at  dancing-school  the  day  before.  The  fever  speedily  rose  to 
points  ranging  from  103°  to  105°,  and  remained  about  these  points 
for  the  first  few  days,  when  it  gradually  became  a  little  less  marked. 
It  failed  to  respond  readily  to  the  use  of  cold  spongings  and  the 
cold  sheet,  as  a  rule,  although  at  times  this  treatment  reduced  it 
considerably.  There  was  but  fittle  cough,  and  at  times  none  of 
it  for  two  or  three  days,  but  the  child  was  somewhat  dyspnoeic, 
particularly  at  night,  and  cyanosis  was  marked.     Thv  \nihe  was 


UI'.SI'lh'A'IOh'Y   <'()M)l'ri<)N,H  IN   ONSHT  .->?, 

usually  HS  iiif^'li  as  120  (o  l.'IO,  ;u)(i  rcsllcssiicss  vvns  f()ii.st;iiit.  At 
times,  particularly  iil  iii[;lil,  (here  Wfis  (Icliriiiiii.  An  (•xiiiiiiiKilion 
of  her  chest  rcvciilcd  ;i(  llic  ri^^lil  inidfllc  lohc  il:c  [diysical  si^us 
of  consolidation-  lliiit  is,  hroiicliiiil  brciidiinif,  diilncss  on  jxtcms- 
sion,  and  al)scncc  of  vesicuiiir  s()nn<ls,  with  exji^gi-ralcd  hrciidn'ri^ 
elsewhere.  At  llic  Icfl  apex  sinn'hir  si<(ns  were  present,  ;ind  il  was 
evident  that  tlie  child  had  j)neuinonia.  '^J^'hc  facijil  expression,  the 
somewhat  dry  lips  and  tontine,  and  the  color  of  die  patient's  skin, 
combined  with  theknowledfije  of  the  fact  that  j)n(iinionia  sometimes 
is  due  to  infection  hy  die  hjicillus  of  Ehcrth,  iiuidc  1))-.  Kirk- 
patrick  (the  physician  who  called  the  senior  aulhor  in  consultation; 
cautious  as  to  the  diagnosis  and  the  prognosis  of  the  case,  and, 
equally  important,  careful  as  to  treatment.  The  parents  were  told 
of  the  condition  of  the  lung  and  of  our  suspicion  that  something 
other  than  a  pure  pneumonic  infection  was  present,  and  we  waited 
for  the  day  of  ordinary  crisis  with  anxiety.  On  the  ninth  the 
temperature  fell  somewhat  and  seemed  to  give  promise  of  relief, 
but  on  the  next  day  it  maintained  its  course;  the  tongue  was  foimd 
to  be  more  like  that  of  enteric  fever  in  appearance,  and  the  rose 
rash  of  typhoid  fever  appeared  on  the  chest  and  belly.  Further, 
careful  palpation  and  percussion  at  this  time  showed  a  slightly 
enlarged  spleen  and  liver,  an  alteration  in  those  organs  not  pre- 
viously found,  and  diarrhoea,  or,  rather  looseness  of  the  bowels, 
supplanted  a  tendency  to  constipation. 

Under  our  older  ideas  of  these  diseases  it  would  have  been 
thought  that  a  primary  croupous  pneumonia  had  merged  into  a 
typhoid  fever  by  a  gradual  process  of  developing  asthenia,  or, 
again,  that  a  double  infection  with  the  Streptococcus  lanceolatus 
and  the  bacillus  of  Eberth  had  taken  place,  whereas,  at  the  present 
time  we  know  that  wliile  such  a  double  infection  is  possible,  a 
single  typhoid  fever  infection  may  result  in  primary  pulmonary 
symptoms. 

Still  an-other  case  is  that  of  B.,  a  man  of  sixty-five  years,  who 
was  taken  ill  ^^^th  general  malaise  and  wretchedness  on  a  certain 
Friday.  Fever  and  chilly  sensations  developed,  but  he  kept  on 
his  feet  for  two  days,  when  he  was  so  ill  that  he  had  to  go  to  bed. 
When  seen  bv  the  senior  author  in  consultation  on  the  fourth  dav 


54  VAh'nrriES  of  ONSF:r 

of  his  illness  there  was  rapid  respiration  (-J2  per  minute),  a  ptilse- 
rate  of  120,  some  cyanosis,  a  feeble,  painful  cough,  and  consolida- 
tion of  the  entire  lower  lobe  of  the  right  side,  with  exaggerated 
breathing  on  the  left  side  of  the  chest.  His  temperatiu'e  rose  from 
102°  to  103°,  and  the  bowels  were  costive  to  a  marked  degree.  The 
s])utiun  was  rusty.  A  diagnosis  of  cr()uj)ous  pneumonia  was  made, 
and  not  until  the  tentli  day  of  his  illness  did  a  persistent  diarrhoea 
of  ochre-colored  stools,  with  rose  spots,  appear.  The  spleen  had 
been  found  enlarged  at  the  first  visit. 

The  difficulty  in  diagnosticating  these  cases  lies  in  the  distincdy 
local  manifestations  and  the  fact  that  in  some  patients  the  fever 
may  be  quite  high,  delirium  of  an  active  form  may  be  marked, 
and  every  symptom  pointing  to  intestinal  typhoid  lesions  may  be 
absent.  The  question  naturally  arises  as  to  the  frequency  with 
which  this  form  of  enteric  fever  occurs,  but  statistics  concerning 
it  are  difficult  to  collect,  since  in  many  instances  the  condition  is 
never  recognized,  or  is  recognized  very  late,  and  is  not  by  any 
means  always  reported. 

There  is  danger  in  these  cases  of  still  another  error  in  diagnosis, 
and  care  must  be  exercised  that  a  diagnosis  of  "pneumotyphoid" 
is  not  made,  when  in  reality  the  condition  is  one  of  tuberculosis 
of  the  lung,  for  in  some  cases  of  this  character  the  rapid  onset  of 
fever,  rigor,  quickened  respiration,  cough,  and  the  development 
of  physical  signs  of  consolidation,  coupled  wnth  the  continuance  of 
fever  after  the  time  for  ordinary  crisis,  ^^•ill  show  that  the  disease 
is  not  croupous  pneumonia.  As  a  matter  of  fact,  the  cases  of 
acute  tuberculous  pulmonary  consolidation  simulating  pneumonia 
at  first  or  "pneumotyphoid"  afterward  are  much  more  frequent 
than  is  pneumotyphoid  itself,  and  careful  study  of  the  case  itself, 
or  its  history,  and  the  microscopic  examination  of  the  sputum 
may  reveal  the  tubercular  character  of  the  process.  In  all  cases  of 
suspected  pulmonary  tuberculosis,  however,  the  absence  of  bacilli 
from  the  sputum  wall  not  negative  the  diagnosis  of  tliis  malady. 
for  until  some  tissue  breakdown  occurs  the  bacilli  may  not  appear 
in  the  sputum. 

It  has  already  been  pointed  out  that  there  is  a  form  of  pneumonia 
ushering  in  typliiod  fever  quite  difl'erent  in  cause  from  that  just 


RESrillATOItY  (JONDiriONS  IN  ONSK'J'  r>o 

Spoken  of,  niuncly,  lli;il  due  lo  doiihlc  inrcchon  will:  ihc  pccific 
organism  of  crouj)oi IS  pnciiiiioiiiii  ;iii(l  (li;i(  of  l\|»lii)ii|  fever.  Sufli 
cases  have  been  dcsciilx-d  j)i(,rl,iciilarly  by  Cliiiiilcinf  ^c  In  iifli 
instances  the  febrile  movement  of  the  jjnenmonia  ni<;r^<!.s  into  that 
of  enteric  fever.  The  early  difrcrcntijil  diagnosis  of  these  two 
conditions  is  practically  impossible,  nnh'ss,  pereli;iiiee,  ihe  b:ieilliis 
of  Eberth  is  found  in  the  feces,  which  is  not  pf^ssiblc  beff>re  the 
ninth  day,  or  the  Widal  test  gives  a  positive  reactifm,  whic-h  it 
rarely  does  in  the  early  days  of  the  malady. 

Acute  pleurisy,  like  acute  pneumonia,  may  usher  in  enteric  fever, 
being  due  to  ordinary  causes  or  to  tyj)hoi{l  fever  infection  of  the 
pleura.  Thus,  Talamon^  has  reconied  a  case  of  enteric  fever  in 
which  the  onset  was  characterized  by  acute  pleurisy,  but  the  con- 
dition differed  from  that  ordinarily  seen  in  this  affection  by  reason 
of  the  intensity  and  persistency  of  the  fever,  and  by  the  general 
depression  and  sleeplessness,  headache,  and  vertigo. 

Talamon  insists  that  there  is  a  distinct  difference  to  be  noted 
between  pleurotyphoid  and  acute  febrile  pleurisy,  for  in  the 
typhoidal  infection  the  general  symptoms  are  out  of  all  proportion 
to  the  physical  signs.  The  only  condition  which  may  closely 
resemble  pleurotyphoid  is  tuberculous  pleurisy,  but  in  tuberculous 
pleurisy  the  temperature  is  remittent,  whereas  that  of  typhoid  is 
rarely  so.  Finally,  the  development  of  the  other  symptoms  of 
typhoid  fever  will  clear  up  the  diagnosis. 

A  very  much  more  rare  respiratory  disorder  \\hich  may  usher 
in  typhoid  fever  is  that  chain  of  symptoms  known  as  laryngo- 
typhoid,  in  which  great  hoarseness  or  aphonia  develops  with  dis- 
tinct evidence  of  acute  laryngitis.  These  cases  are  quite  different 
from  those  of  severe  ulcerating  laryngitis  seen  in  the  advanced 
stages  of  the  disease,  and  which  will  be  considered  later  on  in 
the  chapters  on  the  well-developed  and  convalescing  stages  of  the 
disease.  Such  instances  are  well  illustrated  by  a  patient  described 
by  Bayer.^  A  physician  presented  himself  for  treatment  because 
of  aphonia  and  difficulty  in  swallowing,  wliich  was  fomid  to  be 
due  to  acute  laryngopharyngitis.      These  local   symptoms   were 

1  Talamon.     La  M^decine  Moderne,  May  28,  1892. 

^  Bayer.     Revue  de  Laryngologie,  d'Otologie  et  de  Rhinologie,  July  15,  1893. 


56  VARIETIKS  OF  OX  SET 

improvetl  by  treatiut'iit,  but  in  a  few  ilays  the  man  was  seized  with 
a  severe  chill,  followed  by  fever  and  pain  in  the  throat,  an  exami- 
nation of  which  revealed  a  nvmiber  of  small  superficial  ulcers  on  the 
soft  palate- and  on  the  pharynx;  later  the  characteristic  rose  spots 
appeared  on  the  slsin.  ]\Iore  interestino-  than  all,  ])article.s  of  tissue 
removed  from  the  heads  of  the  ulcers  just  named  contained  the 
bacillus  of  Ebertii.  'l\\v  iuHamniation  exteudetl  to  the  middle  ear, 
and  deafness  resulted.  The  patient  finally  died  from  intestinal 
hemorrhage  and  pneumonia.  The  finding  of  the  bacillus  in  such 
cases  would  enable  an  early  diagnosis  to  be  made.  Lewry^  has  also 
reported  a  case  of  so-called  laryng()tyj)hus  occurring  in  a  child  of 
one  year;  death  occurred  on  the  eighth  day,  and  the  autopsy,  in 
addition  to  revealing  the  intestinal  lesions  of  t}^hoid  fever,  showed 
fibrinous  laryngitis.  Stordeur"  and  Lemaitre^  report  cases  of 
"laryngotyphus"  in  adults.  Blum^  has  also  reported  several  cases 
of  ulcerating  angina  in  typhoid  fever. 

Almost  ecjualiy  rarely  does  a  severe  bronchitis  usher  in  typhoid 
fever  as  a  true  primary  manifestation,  although,  as  the  disease 
progresses,  more  or  less  bronchial  inflammation  is  usually  found. 

Symptoms  of  Onset  in  the  Kidneys. — In  very  rare  instances 
typhoid  fever  develops  with  marked  evidences  of  acute  nephritis, 
the  lu'ine  being  smoky  or  bloody  in  appearance,  and  containing 
albumin  and  casts.  This  form  is  sometimes  called  "nephro- 
typhoid,"  and  Ijy  the  French  "flcvre  typhoide  a  forme  renalc." 

Among:  the  first  of  the  cases  of  this  character  in  the  literature  are 
two  by  Immermann,^  while  the  first  to  describe  the  condition  as  a 
special  disorder  was  Gubler;"  later,  Robin,  a  pupil  of  Gubler,  com- 
pleted the  description  made  by  his  teacher,  and  proposed  the  name 
"nephrotyphoid."  Kussmaul^  was  one  of  the  first  in  Germany  to 
direct  attention  to  the  Gubler-Robin  type,  but  was  not  inclined 
to  consider  it  a  particular  form  of  the  disease  in  the  sense  adopted 
by  some  French  physicians.     Nephrotyphoid  fever,  as  described  by 

»  Lewry.     Archiv  f.  kinderheilkunde,  1888,  Band  xl,  Heft  3. 

*  Stordeur.     Soc.  d' Anatomic  et  Pathologie,  January  21,  1907. 
'  Lemaitre.     Ibid.,  December  13,  1907. 

*  Blum.     Semaine  M6d.,  Paris.,  1908,  xxviii,  37. 

'  Immermann.     Jahresbericht  der  Medic-in.  Abtheilung  des  Burgerspital  zu  Basel,  1872. 

*  Gubler.     Diet.  des.  science  med.,  article  Albuminuria. 

1  Kussmaul.     Homburger,  Berliner  klin.  Wocli.,  1881,  Nos.  20,  21,  22. 


SYMPTOMS  OF  ONSHT   IN    '/'///■:   ALI M  FST  Ml  Y    'lUAC'l'      ",7 

Gul)ler,  is  made  up  f)f'  tlio.s(!  citscs  of  the  disciisf;  in  wliifli  flio 
curliest  symploiiis  are  (hose  relatiii<(  (o  the  kidneys. 

According  to  Anuit,'  (li<'  iirinc  is  in\;ifi;d)ly  clijiriu-leri/fd  l»y  its 
intensely  hloody  eolor  and  the  |)resen(,'(;  (jf  lar^(!  amounts  (;!'  alhiiinin, 
with  numerous  tube  easts,  hlood  eorj)nseles,  epitlieHal  eells,  and 
their  degeneration  produets.  In  nddilion,  there  is  said  to  be  from 
the  onset  remarkably  high  fever,  wilh  cmly  ;ind  profound  stupor, 
but  with  the  absenee  of  the  nsuni  nbdominid  symptoms  of  the 
typical  case  of  typhoid  fever. 

GaillanP  reported  to  the  Soci^t^  M^dicale  des  Ilopitaux,  for 
Bagot,  the  following  interesting  case  of  hsematuria  ushering  in 
typhoid  fever.  The  patient  was  a  lad  of  ten  and  one-half  years, 
who  was  taken  ill  on  June  2<S  with  hsematuria.  On  July  3  the 
patient  suffered  from  a  good  deal  of  tenesmus,  pain  in  the  urethra, 
and  the  urine  contained  retl  blood  cells  but  no  casts.  On  July 
7  distinct  fel^rile  movement  was  noted,  the  child  complained  of 
severe  lumbar  pains,  which  also  extended  into  the  limbs.  He 
then  passed  through  a  typical  attack  of  typhoid  fever,  reaching 
a  normal  temperature  on  July  26,  nearly  a  month  after  the  onset 
of  his  attack.  The  urine  contained  no  blood  after  the  eighteenth 
day  of  his  illness.  Bagot  asserts  that  there  is  no  doubt  whatever 
about  the  correctness  of  the  diagnosis.  That  this  patient  had  a 
distinct  tendency  to  hematuria  seems  indicated,  however,  by  the 
fact  that  in  subsequent  illnesses,  other  than  that  due  to  the  typhoid 
infection,  he  also  suffered  from  this  condition  of  hematuria.  (For 
further  remarks  see  later  chapters.) 

Retention  of  urine  is  sometimes  met  with  in  the  early  stages 
of  typhoid  fever,  but  usually  passes  away  in  a  few  days. 

Symptoms  of  Onset  in  the  Alimentary  Tract. — ^Tonsillar 
inflammation,  associated  with  severe  pharyngitis,  sometimes  begins 
the  course  of  enteric  fever,  and  escapes  correct  diagnosis  as  to  its 
cause  for  a  considerable  period  of  time  because  of  the  situation  of 
the  lesions,  and  also  because  tonsillitis  of  an  active  form  is  so  com- 
monly associated  with  marked  evidences  of  general  systemic  infec- 
tion, the  patient  oftentimes  appearing  profoundly  ill  and  suffering 

1  Amat.     Sur  la  fievre  t>TDh.  en  fomie  renale,  These,  Paris,  1878. 

2  Gaillard.     La  Presse  M«5dicale,  February  11,  1899. 


58  VARIETIES  OF  ONSET 

from  general  wretchetlness,  febrile  movement,  a  heavily  coated 
tongue,  impaired  hearing,  and  mental  hebetiule. 

A  case  of  this  character  was  uiuler  the  care  of  the  senior  author 
when  the  first  eilition  of  this  hook  appeared.  A  woman,  aged  thirty 
years,  was  taken  ill  with  what  appeared  to  be  a  severe  attack  of 
acute  tonsillitis  with  high  fever.  As  the  fever  failed  to  disappear 
with  the  subsidence  of  the  tonsillar  swelling  and  pain,  and  as  an 
epidemic  of  typhoid  fever  was  present,  her  blood  was  examined 
for  the  Widal  reaction.  It  was  found,  and  simultaneously  other 
symptoms  of  enteric  fever  developed. 

A  peculiar  form  of  ulceration  of  the  pharynx  has  been  recorded 
by  Bouveret,^  Devignac,  Dengnet,  Wagner,  and  Cahn.  They  call 
it  "pharyngotyphoid."  The  ulcers  are  superficial,  clean-cut,  and 
appear  chiefly  on  the  soft  palate.     (See  also  later  chapters.) 

(For  oesophageal  lesions,  see  the  next  chapter.) 

Probably  the  most  common  perversions  of  the  early  manifesta- 
tions of  enteric  fever  are  to  be  found  in  association  with  the  func- 
tions of  the  gastro-intestinal  tract.  So  common  are  they,  and  so 
localized  are  the  dominant  symptoms  in  these  cases,  that  the  malady 
seems  quite  distinct  from  true  typhoid  fever,  and  is  often  called 
the  gastric  form  of  typhoid  fever.  In  some  instances,  it  is  true, 
fever  of  mild  degree  develops  in  cases  of  gastric  catarrh  of  a  more 
or  less  severe  form,  but  they  are  not  characterized  by  the  profound 
degree  of  illness  seen  in  the  gastric  type  of  enteric  fever,  in  which 
persistent  vomiting  and  epigastric  disturbance  followed  by  diarrhoea 
are  the  main  symptoms  in  the  early  or  initial  stages.  Such  gastric 
types  are  more  commonly  met  with  in  children.  As  well  pointed 
out  by  Bristowe,  undoubted  enteric  fever  in  cliildhood,  at  which 
age  recovery  commonly  occurs  even  if  the  disease  is  overlooked,  is 
often  called,  for  want  of  a  better  name  and  a  certain  diagnosis,  by 
the  conscience-quieting  term  of  "infantile  remittent  fever,"  "bilious 
fever,"  and  "gastric  fever,"  or  even  "worm  fever."  (See  Frequency 
of  Enteric  Fever  in  Childhood,  in  Chapter  I.) 

The  gastric  manifestations  when  severe  are,  perhaps,  more 
readily  discovered  to  be  due  to  enteric  fever  than  if  the  infection  be 

I  Bouveret.     Berliner  klin.  Woehenschrift    1S85,  No.  14. 


SYMPTOMS  OF  ONS/'JT  IN   'I' I  IF  ALIMENT  MiY   T  If.  ACT     :,\) 

mild,  for,  if  tliis  be  so,  the  oilier  lyphoid  syiriplonis  ;ire  not  iri;irk(;d. 
These  gastric  syinptoins  iire  rarely  met  with  in  (lie  grciit  eilies  of  the 
eastern  part  of  (lie  lliii(('(l  Sdiles,  jukI  v;iry  in  rlidVr^'nl  ♦■piderm'cs, 
although  they  are  asserted  by  Aliirehison  to  have  been  eommonly 
met  with  in  his  experience.  On  the  other  hand,  Hutchinson,  in 
his  classic  article  in  l^epper's  System  of  Medicine,  tells  us  that  these 
acute  gastric  symptoms  with  nausea  and  iulisc  Aoiiii(ing  have  been 
unusual  in  his  exj)erience.  When  vomiting  ushers  in  (he  disease 
in  a  child  it  does  not  seem  to  be  as  evil  a  j)rognostic  sign  as  when 
this  symptom  begins  the  attack  in  ;i!i  ;i(hil(.  The  senior  author  saw 
several  years  ago,  in  consultation  with  Dr.  C^rville  Horwitz,  a  case 
in  which  persistent  vomiting  was  the  first  sign  of  the  disease,  and 
preceded  a  very  severe  illness.  Vomiting  in  a  child  is  readily 
produced  by  any  disturbing  ailment,  but  in  an  adult  it  probably 
results  from  a  more  or  less  profound  infection,  and  rapidly  caases 
exhaustion  if  it  is  persistent,  as  it  is  apt  to  be  in  tliis  class  of  patients. 
When  the  vomiting  is  mild,  or,  in  other  words,  is  repeated  but  once 
or  twice,  it  is  not,  of  course,  of  any  gravity,  and  no  less  an  authority 
than  Murchison  intimates  that  such  cases  often  seem  to  be  bene- 
fited by  it  if  it  be  not  too  persistent. 

Severe  and  continued  vomiting  in  a  case  free  from  malaria  and 
showing  persistent  febrile  movement  ought  to  arouse  the  suspicion 
of  typhoid  infection  to  a  sufficient  degree  to  cause  the  physician 
to  be  on  the  watch  for  further  confirmatory  symptoms,  particularly 
if  the  illness  is  not  relieved  by  the  ordinary  measures. 

Another  variety  of  onset,  represented  by  disturbance  of  the 
gastro-intestinal  functions,  is  that  characterized  by  the  sudden 
development  of  violent  diarrhoea  of  the  serous  type,  instead  of  the 
constipation  usually  met  with  during  the  first  week  of  the  disease. 
Such  cases  are  not  common,  but  are  represented  by  the  follo\A"ing 
case  in  our  own  experience.  A  man  of  thu'ty-five  years,  apparently 
in  perfect  health,  and  whose  appetite  had  been  excellent  up  to  and 
including  the  morning  of  the  beginning  of  his  illness,  began  to  suffer 
after  a  moderately  heavy  luncheon  from  slight  headache,  which  he 
attributed  to  indigestion,  to  which  he  was  subject.  He  ate  no 
supper  because  of  nausea,  and  was  seized  at  twelve  o'clock  midnight 
with  an  active,  watery  diarrhoea,  resembling  a  mild  attack  of  cholera 


60  VARIETIES  OF  ONSET 

morbus,  in  that  tlie  abdominal  pain  was  not  very  severe.  No 
vomitinir  occurred.  Bv  the  use  of  chlorodvne  in  full  doses  he  was 
able  to  remain  out  of  bed  for  four  days,  but  at  the  end  of  that  time 
was  seized  with  a  severe  rigor,  followed  by  moderate  fever  rising 
to  104°.  He  then  developed  mild  typhoid  symptoms,  but  ten  days 
after  the  fever  ceased,  suffered  from  a  severe  relapse.  It  was 
found  that  just  thirteen  days  prior  to  the  diarrhoea  he  had  eaten 
raw  clams  contaminated  by  sewage,  and  that  eight  other  persons 
who  ate  of  the  same  lot  of  clams  also  had  the  disease.  The  active 
diarrhoea  in  this  case,  followed  by  wretchedness  and  general 
malaise,  was  naturally  supposed  to  be  in  no  way  coiuiected  with  a 
definite  and  specific  infection. 

Still  another  case  of  this  kind  is  that  of  a  patient  admitted  to  the 
senior  author's  wards  with  a  history  that  up  to  January  10  he  had 
been  in  good  health,  but  on  that  day,  while  working  in  a  sugar-house, 
and  exposed  to  liigh  temperature,  he  had  taken  large  draughts  of 
cold  water,  which  speedily  produced  symptoms  of  cholera  morbus,, 
followed  by  headache  and  anorexia,  and  these  again  hy  the  early 
symptoms  of  enteric  fever,  which  caused  him  to  come  under  our 
care  a  week  later  with,  as  additional  symptoms,  signs  of  conges- 
tion of  the  middle  lobe  of  the  right  lung.  Rose  spots  appeared 
on  the  ninth  day  of  his  illness. 

Pepper  and  StengeP  have  reported  seven  cases  of  abrupt  onset 
in  typhoid  fever,  and  they  assert  that  Moore,  in  his  Text-hook  of 
Eruptive  and  Continuous  Fevers,  published  in  1S92,  is  the  only 
authority  who  calls  particular  attention  to  these  cases  in  which 
the  disease  begins  abruptly  and  with  vehemence,  characterized  by 
decided  rigors,  violent  headache,  and  rapid  rise  of  temperature. 
Moore  thinks  that  the  whole  course  of  the  disease  is  becoming 
more  typhus-like  than  formerly.  Pepper  and  Stengel's  seven 
cases  may  be  divided  into  two  classes:  those  in  which  the  prelimi- 
nary symptoms  were  simply  gastro-intestinal  in  character,  vomit- 
ing, purgation,  and  high  fever  being  present,  and  others  in  which 
violent  headache  and  catarrh  of  the  throat,  nose,  and  bronchial 
tubes  was  marked. 

'  Pepper  and  Stengel.     Philadelphia  Medical  Journal,  vol.  i,  No.  2. 


^SYMPTOMS  OF  ONSF/r  CONNFCTFU  WIT  1 1  SFUVOdS  SYSTFM    ()] 

Symptoms  of  Onset  Connected  with  the  Nervous  System.  - 
Of  tlic  iicivoiis  iiiHiiircsbid'oii.s  of  (ypli(»i(i  iiiva.si(;ii  lliicc  cliicl'  (y|>»,*.s 
Miiiy  be  nuMitioncd,  iiiuncly:  (a)  'J'hjif  in  wliicli  the  });itif'nt  siiflVT.s 
from  (Iclusions  or  iil)cri';itioii  of  iiiiiid  ;iii(l  u;iiii|cis  from  lioiiif' 
until  he  l)econie.s  so  ill  as  to  fall  ami  be  taken  to  a  licjspital,  or, 
perhaps,  loses  his  life  through  exhaustion,  or  accident  due  to  his 
stupid  mental  state,  or  l)y  means  of  deliberate  suicide,  (h)  The 
second  class  is  that  in  uliicli  Jicnte  maniacal  symptonas  ensue. 
(c)  The  third  class  is  that  in  which  evidences  of  meningitis  are 
marked;  so  marked  that  true  meningitis  is  supposed  to  be  y)r('sent, 
or  in  its  place  meningitis  secondary  to  cr()ii])()iis  jHicumom'a.  In 
many  of  these  cases  there  is  little  doubt  that  the  jjulmonary  lesions 
of  typhoid  infection  are  responsible  for  the  meningeal  signs,  while, 
on  the  other  hand,  it  is  possi})le  for  direct  infection  of  the  men- 
inges by  the  typhoid  organism  to  occur,  although  this  is  rare. 
(See  farther  on.) 

Some  years  ago  one  of  us  (Hare)  and  Patek  reported  two  cases, 
and  collected  a  number  of  others  of  mental  disturbance  at  the  onset 
of  the  disease  which  we^  found  in  the  literature  of  the  subject: 

Murchison^  reports  the  case  of  a  German  who  w^as  much  excited 
over  the  Franco-Prussian  War.  After  about  four  days  of  dis- 
comfort and  malaise,  he  suddenly  passed  into  a  state  of  acute 
maniacal  delirium,  requiring  two  men  to  control  him.  There  was 
an  absolute  refusal  of  food,  a  temperature  of  102°,  with  a  dry  tongue 
and  rapid  pulse,  shght  diarrhoea,  and  no  spots.  The  patient  w^as 
subdued  by  large  doses  of  chloral,  and  the  fever  ran  its  course. 
The  same  author  also  states  that  in  several  instances  he  has  known 
acute  mania  to  develop  on  the  first  day  of  an  enteric  fever,  and  that 
under  these  circumstances  the  case  is  very  apt  to  be  mistaken  for 
insanity. 

Wilson^  asserts  that  delirium  may  be  an  early  symptom  of 
enteric  fever,  and  quotes  Riberalba,  who  reported  four  cases  which 
were  delirious  on  admission  to  the  hospital.  Louis  saw  two  cases 
w^iich  were  delirious  on  the  first  nio-ht  of  their  illness.     Bristowe 


1  Hare  and  Patek.     :Medical  News,  1S92. 

2  Murcliison.     Lancet,  1870,  vol.  ii,  p.  807. 

3  Wilson.     Philadelphia  Medical  Times,  1884-85,  vol   xv,  p.  577-5S1. 


62  VARIETIES  OF  ONSET 

has  also  reported  a  case  in  wliic  h  maniacal  delirium  existed  on  the 
second  day.  Mottet  mentions  an  instance  of  typlioid  fever  com- 
plicated ■with  mania  to  such  a  marked  extent  that  the  patient  was 
placeil  in  an  asylum  before  the  true  nature  of  the  ailment  was 
discovered,  and  Ilenrot  antl  Buccpioy  have  seen  the  disease  ushered 
in  with  the  delirium  of  grantleur.  Finally,  Daly^  records  an 
instance  in  which  aggressive  mania  came  on  on  the  fifth  day,  fol- 
lowing a  condition  of  stupor. 

One  of  us  (Beartlsley)  saw  the  following  case  in  1903:  The 
patient  was  a  man,  aged  thirty-two  years,  who  had  never  sulf'ered 
from  any  previous  illness  and  had  heen  perfectly  well  mentally 
and  physically  until  a  week  preceding  his  admittance  to  the  hos- 
pital. Three  weeks  preceding  his  illness  his  wife  was  taken  ill  with 
typhoid  fever.  She  was  pregnant  at  this  time,  and  in  the  tliird 
week  aborted.  A  few  days  following  this  occurrence  it  was  noticed 
that  the  husband  was  despondent  and  silent,  but  little  was  thought 
of  this,  as  the  friends  knew  how  bitter  a  disappointment  the  loss  of 
the  child  was  to  him.  Two  days  after  this  change  in  the  mental 
attitude  of  the  man  he  was  suddenly  seized  with  homicidal  mania 
and  attempted  to  kill  his  wife  by  beating  her  with  a  chair,  and 
assaulted  those  who  came  to  her  rescue.  Examination  revealed  a 
roseolar  eruption  upon  liis  abdomen  and  back.  The  patient  died 
four  days  after  being  removed  to  the  hospital,  and  the  autopsy 
revealed  the  characteristic  lesions  of  typhoid  fever. 

From  a  careful  examination  of  a  large  amount  of  literature  we 
are  convinced  that  prodromal  insanity  in  enteric  fever  is  most 
rare  and,  when  it  occurs,  is  almost  always  fatal,  while  the  insanity 
which  is  in  the  nature  of  a  sequel  may  be  looked  upon  as  devoid 
of  danger  to  mind  or  body. 

In  very  rare  instances,  delirium  may  be  almost  the  first  symp- 
tom of  typhoid  fever.  Indeed,  it  may  actually  precede  the  devel- 
opment of  pyrexia;  thus,  in  seventeen  cases  which  have  been  col- 
lected from  literature  by  Aschaffenbourg,^  seven  were  charac- 
terized by  the  development  of  delirium  before  the  fever,  and  the 
latest  period  at  which  it  was  observed  among  these  cases  of  early 

1  Daly.     The  Medical  New.s,  1882,  vol.  xl,  p.  68. 

*  Aschaffenbourg.     Archives  de  Neurologic,  March,  1895. 


SVM/'TOM.S  OF  (>^SI<:T  CON N KCT HI)  Wl'l'll  NHH.  VOUS  S  VSThWf    i\?, 

(Iclii'iiiin  wn.s  llic  end  of  (lie  fir.sl  week.  >\.s  ;i  rule,  (Ik;  dcliriijiri 
lasted  only  a  lew  diiys,  hnl,  (he  nior(;ilil,y  vvjis  lii^li,  .six  of  tlif; 
sevoii(('(>n  ])aticiits  dyiiin;.  Airion<(  tlicsc  cases  tlie  delirium  occurred 
in  two  I'ornis,  either  (lie  |);i(ieiils  were  exeeedint^ly  restless  and 
violent,  finally  becoming  torpid,  or  there  was  a  condition  of  confu- 
sional  insanity,  in  which  the  patients  sang,  prayed,  danced,  or  were 
gay  or  sad. 

The  following  cases  met  with  by  the  senior  author  and  J^atek 
are  of  interest:  Amiie  M.,  aged  twenty-four  years,  wa.s  admitted 
to  St.  Agnes'  Hosi)ital,  March  IS,  LSOl.  She  had  been  feeling 
badly  for  some  time,  but  undl  loin-  days  previously  had  been  able 
to  do  her  work.  On  the  14tli  she  had  a  severe  headache,  vomited 
a  little,  suffered  from  pain  in  the  stomach,  and  had  some  diarrhoea, 
these  symptoms  being  followed  on  the  subsequent  day  by  not  very 
profuse  epistaxis.  She  walked  a  considerable  distance  to  the  hos- 
pital, and  on  her  admission,  at  10  p.m.,  her  temperature  was  found 
to  be  105°.  The  resident  physician  found  that  her  tongue  was 
thickly  coated,  dry,  and  brown.  On  the  next  day,  when  seen  in 
the  wards,  the  tongue  was  unusually  clean  even  for  that  of  a 
healthy  person.  The  patient  was  delirious  and  so  violent  that 
it  required  several  persons  to  keep  her  in  bed.  The  tempera- 
ture, after  an  unusually  prolonged  and  severe  struggle,  was  found 
to  be  106°. 

At  tliis  time  every  symptom  of  typhoid  fever  was  completely 
masked  by  the  insanity.  The  bowels  were  moved  and  the  passages 
were  of  normal  consistency  and  color.  The  urine  was  somewhat 
scanty  and  high  colored,  and  the  pulse  full  and  strong.  There 
were  no  rose  spots  or  other  enteric  symptoms.  At  the  end  of 
twenty-four  hours  the  patient,  still  being  in  a  condition  of  ^ild 
insanity,  was  removed  to  a  cell,  the  impression  being  that  it  might  be 
a  case  of  hysterical  mania  with  hyperpyrexia.  Twenty-fom'  hours 
later  the  insanity  had  disappeared,  and  the  t}-phoid  symptoms  as- 
serted themselves;  the  delirium  became  more  quiet  and  muttering, 
and  she  was  taken  back  to  the  wards.  Durino-  the  following^  week 
she  was  constantly  delirious,  and  frequently  maniacal,  although 
there  were  short  momentary  intervals  of  sanity.  Diu-ing  this  time 
a  large  number  of  rose  spots  appeared  on  the  abdomen  and  chest. 


64  VAEIETIES  OF  ONSET 

the  tongue  became  lieavily  and  typically  furred,  the  temperature 
followetl  a  characteristic  course,  the  typhoid  odor  was  present,  and 
an  occasional  nose-bleed  helped  to  confirm  the  diagnosis  of  typhoid 
fever.  She  rai)i(lly  became  worse,  and  died  thirteen  days  after 
admission,  without  becoming  sane,  except  for  the  bi-ief  intervals 
named. 

The  second  case  is  as  follows : 

jNIr.  A.,  a  resident  of  Milwaukee,  aged  thirty-four  years;  mar- 
ried; one  child.  A  sister  died  of  convulsions  of  imknown  nature 
but  a  short  time  before  the  onset  of  his  illness.  Family  history 
otherwise  negative.  At  the  age  of  seventeen  years  the  patient, 
according  to  the  statement  of  his  physician,  had  an  attack  of 
typhoid  fever,  attended  with  as  much,  if  not  more,  delirious 
excitement  than  this,  the  second  attack.  The  history  of  the  case 
begins  with  the  circumstance  that  Mr,  A.  was  nursing  his  wife, 
who  was  down  with  a  mild  attack  of  typhoid.  The  })atient's  first 
complaint  was  of  headache  and  insomnia.  The  visiting  physician, 
seeing  him  on  the  following  day,  ordered  him  to  bed,  recognizing 
the  case  as  one  of  typhoid  fever,  rather  because  of  the  existence 
of  a  like  case  in  the  same  house  and  from  the  mere  complaint  of 
malaise,  than  from  any  symptoms  particularly  characteristic  of  the 
disease.  The  patient  obeyed  the  instructions  of  the  physician,  and 
went  to  bed,  still  complaining  of  insomnia.  Hardly  had  he  fallen 
into  a  mild  slumber  when,  not  more  than  an  hoiu*  later,  he  sud- 
denly awoke,  delirious,  and  grew  steadily  more  so.  During  the 
following  night  he  became  maniacal,  rushed  to  the  room  of  the 
nurse  (she  had  been  procured  since  the  husband's  illness),  burst 
open  the  door,  threw  the  nurse  to  the  floor,  and  assaulted  her  in 
a  most  violent  manner,  kicking  and  striking  her,  and  accusing  her 
of  wishing  to  harm  his  wife  and  child.  The  nurse  finally  man- 
aged to  escape,  and  ran  for  the  physician,  who  lived  across  the 
street.  In  the  meantime  the  patient  jumped  through  a  window 
leading  to  a  small  balcony  over  the  front  portico,  and  leaped  to 
the  ground,  where  he  was  found  a  few  minutes  later  by  the  physi- 
cian. Strange  to  say,  the  man  suffered  little  injury,  being  slightly 
bruised  by  the  fall,  and  somewhat  cut  by  the  glass;  but  stranger 
still  was  the  fact  that  he  was  now  quite  rational,  telling  the  physi- 


SYMPTOM S  OF  ONHliT  CONN I'^CT HI)  WITH  N/'JUVOf/S  SYSTf'JM   05 

ciaii  all  tliiit  had  tran.sj)irc(l  and  wliai  lie  li;id  done  'i'iic  paiicnt 
was  again  ])ut  to  Ixvl,  now  iij)|)iir('nlly  (\\uic  <  oniforhdjlf'.  'JMu; 
physician  left  him  (o  sec  the  wife  in  ;in  ;idjoinin^f  room.  Ihirrlly, 
however,  had  he  gone  wlicji  Mr.  A.  .snd(h-iily  sj)r;ing  from  th(; 
bed,  rushed  into  the  kitchen,  where  he  seized  ;i  large  knife,  and 
then  hurried  back,  bent  upon  assaulting  du;  physician.  He  was, 
however,  overpowered  and  again  forced  to  bed.  He  now  rested 
comfortably,  and  when  seen  the  following  day  was  df>ing  well. 
That  evening  a  condition  of  hyperj)yrexia  suddenly  intervened, 
and  in  a  few  hours  the  jjatient  was  dead. 

The  following  case  is  of  interest  in  this  connection,  and  was 
seen  by  the  senior  author  through  the  courtesy  of  Dr.  Higbee,  of 
Philadelphia,  who  called  him  in  consultation. 

An  unusually  large,  muscular  man,  al)out  thirty-five  years  of 
age,  after  two  or  three  days  of  wretchedness  and  malaise,  with 
slight  headache,  developed  fever  of  moderate  degree  on  the  fourth 
day,  and  that  evening  became  maniacally  delirious,  so  that  it 
required  four  of  five  of  his  fellow-workmen  to  hold  him  in  bed. 
On  these  workmen  becoming  exhausted,  the  following  night  two 
male  nurses  were  put  in  charge  of  liim,  but  he  fought  them  so 
vigorously  that  they  refused  to  take  care  of  the  patient  when  the 
morning  arrived,  as  they  stated  he  was  so  powerful  that  he  tlirew 
them  all  about  the  room. 

When  seen  after  two  nights  of  violent  delirium  of  this  character, 
he  was  perfectly  himself,  mentally,  and  described  liis  condition 
and  liis  sensations,  using  unusually  good  English  for  a  man  in  his 
walk  of  life,  and  evidently  having  an  intelligent  idea  of  the  chief 
symptoms  to  which  he  was  subject.  He  had  no  recollection  of  his 
delirium,  but  he  had  been  told  bv  his  ^\ife  of  the  strugo-les  that  ther 
had  had  with  him  on  the  previous  night. 

A  careful  examination  of  his  chest  revealed  at  the  apex  of  the 
right  lung,  anteriorly,  a  small  patch  where  there  was  impaired 
resonance  and  the  other  physical  signs  of  pulmonary  consolidation, 
and  after  consultation  we  agreed  that  it  was  one  of  those  cases  of 
pneumonia  in  which  there  was  a  remarkably  small  pulmonary  lesion, 
accompanied  by  severe  meningeal  and  cerebral  symptoms.  Some- 
tliing  about  the  case,  however,  made  us  suspicious  of  a  t^'phoid 
5 


66  VARIETIES  OF  ONSET 

infection,  and  wliile  there  were  no  .symptoms  of  typhoid  fever  pres- 
ent that  coiikl  be  pointed  to,  we  were  suspicious  of  the  development 
of  tliis  disease.  That  evening  the  man  again  became  maniacally 
delirious  to  such  an  extent  that  his  family  recognized  that  it  was 
impossible  to  keep  him  at  home,  and  he  was  admitted  to  the 
hospital,  where  he  died  in  forty-eight  hours  from  exhaustion. 
The  autop.sy  revealed  typical  typhoid  ulceration  of  the  bowel  and 
other  pathological  evidences  of  well-marked  tyi)hoid  fever. 

This  case  illustrates  very  well  not  only  the  fact  that  pneinnonia 
and  typhoid  infection  may  exist  side  by  side,  the  pulmonary  con- 
dition being,  perhaps,  directly  due  to  the  infection  of  the  bacillus 
of  Eberth,  but  also  that  cerebral  symptoms  of  great  severity  may 
usher  in  both  typhoid  fever  and  pneumonia. 

Osier  records  two  cases  of  curious  aberrant  mental  state  in  tlie 
stage  of  onset.  In  one,  a  young  girl  began  her  illness  by  doing- 
odd  things  and  having  laughing  and  crying  spells;  the  other, 
also  a  young  woman,  was  distinctly  "off  her  head,"  so  that  she  was 
regarded  as  an  ordinary  case  of  insanity. 

There  is  still  another  nervous  type  of  onset  which  is  exceed- 
ingly rare,  namely,  that  of  rapidly  developing  stupor  and  coma. 

Very  rarely  in  children  the  disease  is  ushered  in  by  a  convul- 
sion, as  in  a  case  recorded  by  Osier,  and  in  the  case  of  convul- 
sions reported  by  Green,  and  detailed  in  an  earlier  part  of  this 
essay.  Convulsions  when  met  with  in  adults  are  usually  seen  in 
the  later  portions  of  the  disease,  and  depend  upon  embolism  or 
thrombosis  of  important  cereljral  vessels. 

The  Skin  in  the  Stage  of  Onset. — As  is  well  known,  the  char- 
acteristic rash  of  typhoid  fever  does  not  make  its  appearance, 
as  a  rule,  until  the  seventh  or  ninth  day,  and,  therefore,  it  cannot 
be  considered  a  symptom  of  onset  in  typhoid  fever.  Cases  do  occur, 
however,  in  which  in  this  stage  of  the  disease  aberrant  rashes 
develop.  Thus  the  senior  author  had  under  his  care  a  man  of 
twenty-two  years,  who  entered  the  hospital  on  the  third  day  of  his 
illness  so  covered  by  a  profuse  scarlatiniform  rash  that  a  differential 
diagnosis  as  to  its  true  character  was  impossible.  It  persisted  for 
three  days,  and  then  gradually  faded,  and  the  case  ran  a  course  of 
typical  typhoitl  fever.  (See  the  chapters  on  the  skin  in  the  well- 
developed  and  convalescent  stages.) 


77//';  SKIN   IN   TUI'l  STACi:  OF  ONSFT  67 

The  junior  author,  during  a  service  in  llic  ,Sf:iil(i  I'cvcr  Wards 
at  the  Municipnl  II(),sj)itiil  of  rhila(i(;lj>hiii,  siiw  ;i(,  their  homes 
three  cases  of  typhoid  fever  in  chiNhHui  in  vvliom  there  was  a  pro- 
dromal scarhitini  form  i;i.sli  which  in  every  way  corresponded  tolhf; 
rash  of  scarlet  fever,  and  had  it  not  been  for  a  careful  infjuiiy  into 
the  previous  Jiistory  of  these  patients  they  would  have  been  taken 
into  the  hospital  as  scarlet  fever  subjects. 

In  reference  to  these  rashes,  Dr.  IJurvill-IIohnes,  who  spent  three 
years  at  the  Municipal  Hospital,  informs  us  that  durinf^  this  period 
he  saw  three  similar  cases,  one  of  which,  enterinf^  the  hospital 
because  of  an  error  in  diagnosis,  was  exposed  to  and  contracted 
scarlet  fever,  thus  giving  an  excellent  exam[)Ie  of  (he  similarity 
of  the  two  rashes. 

Remlinger^  has  carefully  studied  these  prodromal  rashes  of 
typhoid  fever,  and  has  reported  that  in  the  49  examples  that  he 
was  able  to  find  in  the  literature,  there  were  31  examples  of 
morbiUiform  rashes,  4  of  scarlatinal  rash,  and  14  in  which  there 
was  a  mixture  of  the  two  types. 

1  Remlinger.     Revue  de  Medecine,  1906. 


CHAPTER    TIT. 

THE  ABERRANT  SYMPTOMS,  STATES,  OR  COMPLICATIONS  OF 

THE  WELL  DEVELOPED  STAGE  OF  THE  DISEASE. 

Temperature  in  the  Developed  Disease. — We  may  pass  on, 
then,  to  a  consideration  of  excessive  symptoms  and  com})lications  of 
the  developed  disease,  and  its  febrile  process  natnrally  first  attracts 
attention.  Before  we  attempt  to  study  the  unusual  febrile  condi- 
tions seen  in  patients  who  have  passed  the  stage  of  onset  and  are 
in  the  well-developed  period  of  the  malady,  it  may  be  well  to  con- 
sider briefly  the  normal  or  usual  febrile  movement. 

This  Striimpel  well  describes  when  he  says  that  the  second  division 
of  the  curve  represents  the  so-called  fastigium,  and  corresponds  to 
the  height  of  the  disease.  "During  this  time  the  fever  presents 
in  most  of  the  severer  cases  the  general  character  oi  febris  continua 
— that  is,  the  spontaneous  remissions  of  the  fever  seldom  exceed 
2°.  Almost  always  the  lower  temperatures  come  in  the  morning 
hours  and  the  liigher  in  the  evening.  In  cases  of  average  severity 
the  morning  remissions  touch  102°  to  103°,  and  the  evening 
exacerbations  104°  to  105°.  Temperatures  which  reach  or  exceed 
106°  are  seen  only  in  very  severe  cases.  Considerable  morning 
remissions  are  always  a  favorable  symptom,  while  morning  tem- 
peratures of  104°,  or  higher,  generally  show  the  case  to  be  severe 
The  duration  of  the  fastigium  varies  with  the  severity  and  obsti- 
nacy of  the  case.  It  may  last  only  a  few  days  or  one  and  a  half 
to  two  weeks;  in  violent  cases  still  longer." 

Ampugnani^  has  proved  that  the  natural  maximiun  occurs 
between  3  and  6  p.m.,  and  tlie  natural  minimum  between  5  and 

8.  A.M. 

At  the  end  of  the  fastigium  the  temperature  gradually  falls 
by  lysis  until  it  reaches  the  normal,  or  perhaps  more  frequently 

1  Ampugnani.     London  Medical  Record,  January,  1889. 


TEMi'i<:i{.A'i'Uiii<:  IN  rill':  dicvkloi'i:!)  nishiASh:         no 

there  is  hd'orc  \\\v  lysis  jiiiollici-  period  vsliidi  li:i  ,  Ixiii  f.-iUcil  hy 
Wniidcrlicli  (lie  " jiiiiM^iioiis  period,"  in  wliieli  llie  inoniiri^  Icm- 
pcrutures  arc  cacli  day  almosi  rionnal  and  llie  eveiiin/f  f,eiri[)('ra- 
tures  only  sli<i;litly  lower  each  day.  In  odier  eases  (lie  evening 
tem])('rature  for  some  days  remains  as  In'^h  as  before.  Miirehisori 
called  this  period  "the  stage  of  changing  fortunes,"  and  Strurnpel 
has  called  it  "the  period  of  steep  curves,"  and  has  also  .stated  that 
the  longer  a  case  lasts  the  more  marked  becomes  the  irregularity 
of  the  fever  at  this  time. 

The  case  recorded  in  the  chai-t  (Fig.  llj  was  one  of  very  great 
interest,  because,  as  the  fever  of  the  early  stage  of  the  disease  was 
not  marked,  and  the  abdominal  symptoms  were  prominent,  the  ques- 
tion arose  as  to  whether  tlie  patient,  who  was  five  months  pregnant, 
was  suffering  from  appendicitis,  uremia,  sepsis  from  pelvic  disease, 
septic  endocarditis,  or  typhoid  fever.  There  was  scantiness  of  the 
urine,  half  the  normal  amount  of  urea,  albuminuria,  and  marked 
signs  of  general  toxaemia.  There  was  also  great  tenderness  of  the 
belly,  particularly  over  the  appendix,  and  considerable  pain  in 
this  region,  even  when  the  patient  was  lying  still.  In  addition 
there  was  also  great  difficulty  in  urination  and  obstinate  constipa- 
tion, and  the  pregnant  uterus  so  filled  the  lower  segment  of  the 
belly  and  displaced  the  bowels  that  diagnosis  was  unusually  diffi- 
cult. Auscultation  over  the  prsecordium  revealed  a  distinct  endo- 
cardial murmur,  probably  due  to  the  anaemia  of  pregnancy. 
Had  these  steep  curves  been  met  when  the  patient  was  first  seen 
the  case  would  have  been  considered  one  requiring  operation, 
because  they  would  have  led  us  as  w^ell  as  the  surgical  consultant 
to  believe  that  the  symptoms  w^ere  septic.  The  development  of 
a  profuse  rose  rash  and  the  Widal  reaction  cleared  the  diagnosis 
some  days  before  the  period  of  steep  ciu-ves  began. 

Having  set  up  a  normal  standard  for  the  com-se  of  typhoid 
fever,  we  find  that  variations  from  this  standard  often  occur,  and 
many  of  these  are  indicative  of  some  condition  well  worthy  of  the 
physician's  attention.  It  is  also  true,  on  the  other  hand,  that  some 
aberrations  are  without  significance  so  far  as  om*  present  knowledge 
goes.  The  temperature  of  typhoid  fever  is,  as  is  well  known, 
rarely  as  high  as  in  many  other  of  the  grave  infectious  maladies, 


70 


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TEMPl'JUATUliJ'J  IN   TJJ/'J   DI'AICLOI'I':!)   hISHASI-:  7| 

yet  at  times  it  m;i,y  beeorne  in  itself"  (|jiii(ren;u,s  \>y  r<;;i.sf;ii  of  its 
Iiei<(ht.  Sometimes,  tiioiif^ii  rarely,  as  in  I  lie  (Jays  of  rxisef,  we  meet 
(liiriii((  the  fastif^ium,  without  tiie  presentee  of  an  a(l(h'lion;il  exeiting 
cause  over  and  above  the  ordinary  typhoid  infection,  \\i(h  f,a.ses 
in  which  there  is  (k^veloped  a  distinct  hyper[)yrexia  jniioniidii^'  to 
105°,  or  even,  very  rar(;ly,  to  110°. 

Such  hi<i;h  tenipera lures  are  sometimes  seen  for  lono-  periods  of 
the  attack  as  the  result  of  nervous  excitement,  or  of  unusual  sas- 
ceptibility  to  the  infection  in  the  sense  that  the  heat  mechanism  is 
easily  disturbed  by  the  disease.  These  cases,  as  a  rule,  however, 
do  not  persist  in  hyperpyrexia,  but  soon  fiill  fo  (lie  usual  level. 
When  the  fever  is  persistently  high  there  can  l)e  no  doubt  that,  as 
a  rule,  the  attack  is  one  of  a  severe  character.  C.'onversely,  a  low 
range  of  fever  is  indicative  of  a  mild  attack,  although  by  no  means 
proof  of  it,  for  moderate  fever  is  sometimes  seen  in  cases  charac- 
terized by  very  severe  infection.  Rarely  the  disease,  pursuing  a 
fatal  course,  is  accompanied  by  progressively  rising  fever  until, 
toward  the  end  of  the  second  or  third  week,  it  may  reach  107°  or 
even  110°,  as  has  been  recorded  by  Wimderlich. 

Wlien  a  severe  and  prolonged  attack  of  typhoid  fever  is  present 
the  period  of  "steep  curves"  may  be  postponed  from  the  end 
of  the  third  or  beginning  of  the  fourth  week,  or  even  to  the  fifth 
or  sixth  week,  and  in  these  cases  there  is  usually  ^^^despread 
ulceration  of  the  small  and  large  intestine.  Additional  evidence 
of  tliis  condition  is  adduced  by  the  fact  that  the  abdomen  is  still 
tender  on  pressure,  and  the  so-called  meteorism  or  active  peris- 
taltic movement  is  persistent.  Care  must  be  taken  in  these  cases 
that  other  causes  than  uncomplicated  typhoid  fever  are  not  actively 
engaged  in  the  continuance  of  the  fever,  either  in  the  form  of  other 
infections  or  as  secondary  infections  by  the  bacillus  of  Eberth  of 
such  parts,  for  example,  as  the  gall-bladder,  the  kidney,  or  the  bones. 
Or,  again,  the  fever  may  be  continuous  as  the  result  of  a  tubercu- 
lous infection  superimposed  on  the  typhoid  trouble  or  antedating 
that  disease  in  time  of  entrance  into  the  body,  but  only  active 
when  vital  resistance  is  decreased  by  the  exhaustion  of  t^'phoid 
fever.     (See  farther  on.) 

Among  the  particularly  noteworthy  causes  of  sudden  rises  of 


72  ^V ELL-DEVELOPED  STAGE  OF  THE  DISEASE 

fever  during  the  fastigium,  or  in  the  period  of  ambiguity,  or 
during  lysis,  we  find  the  development  of  some  acute  complica- 
tion, such  as  pneumonia,  catarrlial  or  croupous,  abscess  in 
some  part  of  the  body,  and  wliat  has  been  called  "intercurrent 
relapse."  The  ]Mieumonia  at  this  period  is  often  of  the  croupous 
t}'pe,  and  pleurisy  may  also  develop,  but  their  onset  may  not 
noticeably  disturb  the  temperature-curves,  so  that  while  the 
presence  of  a  rise  may  be  indicative  of  another  source  of  diffi- 
culty, its  absence  does  not  indicate  that  no  secondary  pulmonary 
trouble  has  arisen;  more  rarely  still  catarrhal  pneumonia  elevates 
the  temperature,  and  its  very  insidious  onset  makes  it  readily  over- 
looked, and  the  development  of  hypostatic  congestion  may  make 
no  change  at  all.  The  temperature  under  some  circumstances  rises 
quite  suddenly,  and,  after  maintaining  a  generally  higher  course 
for  a  few  days,  begins  to  drop  back  to  its  former  level,  or  at  once 
the  whole  temperature  course  passes  into  the  stage  of  lysis.  So, 
too,  an  otic  abscess  may  produce  such  results,  and,  finally,  should 
an  intercurrent  relapse  ensue,  the  fever,  gaining  new  force,  may 
mount  to  a  point  as  high  or  higher  than  any  previously  reached, 
and  last  from  ten  days  to  two  weeks  or  more,  falling  again  as  a 
tendency  to  lysis  is  developed.  The  presence  of  a  mild  primary 
attack  followed  by  a  relapse  after  several  days  of  no  fever,  and 
finally  complicated  by  phlebitis,  with  fever  secondary  to  it,  and 
then  a  second  relapse,  is  shown  in  the  chart  (Figs.  12  and  13). 

It  is  important  that  a  secondary  exacerbation  of  the  fever 
be  not  regarded  as  indicative  of  true  relapse  unless  it  persists, 
and  is  followed  by  a  renewal  of  many  or  all  of  the  earlier  symp- 
toms of  the  disease,  and  unless  the  eruption  and  enlargement  of 
the  spleen  a  second  time  indicate  true  secondary  infection.  Not 
only  is  the  physician  to  avoid  a  diagnosis  of  relapse  until  it  is 
proved  to  be  present,  for  the  sake  of  accuracy,  but  in  addition  he 
must  avoid  it,  because  it  is  an  easy  way  to  explain  temperature 
irregularities,  which  should  cause  him  to  carefully  search  for  com- 
plicating affections.  To  sum  up  this  matter  with  brevity,  it  should 
be  the  rule  to  consider  any  sudden  and  considerable  rise  of  fever, 
above  the  ordinary  lines  previously  followed,  as  indicative  of  some 
other  factor  than  the  ordinary  typhoid  infection.     These  various 


TEMri'JiiATURJiJ  IN  Till':  hi:v i:l(>I' I,!)  i)isr:.\sH         ~.>, 

C()inf)li('ji,lHif^  sfjiics  wliifli  nrc  prodiiclivc  ol'  fchrilc  iiio\ciii<-;il  will 
be  (iiscusscd  later  on  wlicii  sliidyin^r  (Jic  lesions  Joini'l  in  \;irions 
organs. 

Of  the  cases  in  wliicli  (he  (cniixTudn-c  is  o'i  low  (je^rce  ;iikI 
mild,  much  may  be  said.  In  llie  lirsl  place,  in  very  rare  insfanee.s 
cases  occur  in  wliicli  there  is  not  only  no  fever,  but  jie(u;dlv  a  rori- 
dition  of  subnormal  temperature  from  the  beginnin^j,  lo  die  end  of 
the  attack.  Thus,  in  several  cases  under  our  care,  some  years  since, 
there  was  a  characteristic  temperature  curve  in  form,  but  not  in 
degree,  the  morning  temperature  being  distinctly  subnormal  and 
the  evening  temperature  normal,  and  in  which  the  rel nin  to  health 
consisted  in  a  "lysis,"  so  to  speak,  in  which  the  temperature 
gradually  rose  to  normal  instead  of  falling.  Again,  almost  equally 
rarely  there  is  no  temperature  movement  whatever  in  the  sense 
that  the  temperature  is  either  above  or  below  normal. 

Cases  of  this  type  have  been  recognized  for  many  years  by  close 
students  of  the  disease,  but  are  not  commonly  recognized  by  the 
general  practitioner,  who  is  taught  in  the  medical  schools  to  regard 
fever  as  a  necessary  symptom  of  this  malady.  Many  years  ago  the 
elder  Miescher  recognized  these  cases,  and  Liebermeister  recorded, 
in  1869,  139  cases  of  "afebrile  abdominal  catarrh,"  which  he 
thinks  were  in  large  part  due  to  typhoid  infection,  and,  in  1870, 
111  cases  of  the  same  character.  Many  of  these  cases  showed 
evident  enlargement  of  the  spleen,  and  in  some  instances  a  roseola. 
Straube^  has  described  fourteen  cases  in  which  no  fever  was  pres- 
ent, although  at  times  the  temperature  was  subnormal,  and  in 
which,  nevertheless,  the  other  characteristic  symptoms  of  enteric 
fever  were  present  to  so  marked  a  degree  that  they  could  not  be 
mistaken  for  any  other  disease.  The  mortality  in  these  cases  was 
no  less  than  14.1  per  cent.  So,  too,  FraentzeP  has  recorded  forty- 
one  cases  treated  in  a  field  hospital  during  the  Franco-Prussian 
War,  in  three  of  wliich  the  fever  did  not  exceed  99.1°,  and  in  the 
rest  did  not  rise  above  102.2°,  and  yet  in  wliich  the  mortahty  was 
39  per  cent,  for  the  forty-one  patients.     Guiteras^  records  a  case,  in 


1  Straube.     Berliner  klin.  Wochensclirift,  1S71,  No.  30. 

2  Fraentzel.     Zeitsclirift  fiir  klinische  Medizin,  ISSl,  p.  226. 

2  Guit^ras.     Transactions  of  the  Association  of  American  Physicians,  ISS". 


74 


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76  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

which  lie  diagnosticated  the  condition  as  intestinal  obstruction, 
in  wliieh  the  patient  died  of  peritonitis,  and  at  the  autopsy  the 
lesions  of  typhoid  fever  were  found,  although  no  fever  had  been 
present.  Vallin^  records  a  case  of  death  due  to  perforation  in  an 
afebrile  typhoid  fever  patient,  and  another  of  intestinal  hemor- 
rhage in  a  similar  case,  and  the  senior  author  has  seen  several 
afebrile  cases  in  one  epidemic.  In  still  another  epidemic  another 
instance  was  met  with,  which  has  been  recorded  in  the  Memphis 
Lancet  for  July,  1898.     (See  farther  on.) 

In  La  Provence  Medicale  for  November  26, 1897,  Weil  and  Fiery 
reported  a  case  of  apyretic  typhoid  fever,  which  they  considered  in 
every  way  typical  in  other  respects.  Godfrey  Carter^  has  reported 
another  case  of  this  kind,  while  Judd"^  had  under  his  observation 
a  young  woman  who  after  exposure  to  typhoid  fever  developed  all 
the  classical  signs  and  symptoms  of  the  disease  except  the  fever. 
The  patient  was  placed  in  bed  and  carefully  observed.  There 
was  no  temperature  until  the  seventeenth  day  of  the  illness,  when 
the  patient  developed  tenderness  over  her  saphenous  vein  and  her 
temperatiu"e  rose  to  101.6°.  Four  days  later  the  temperature 
became  normal,  and  convalescence  became  established. 

Gerhardt*  and  Dreschfeld^  have  also  reported  cases  of  this  char- 
acter, and  there  has  even  been  reported  an  epidemic  of  apyretic al 
typhoid  fever  by  Fraentzel.®  It  is  interesting  to  note  that  the  course 
of  these  ap}Tetic  cases  was  quite  as  severe  as  the  cases  having 
fever. 

Two  cases  of  apyretic  typhoid  fever  have  also  been  recorded  by 
Wendland.^  These  cases  were  confirmed  by  autopsy,  and  illus- 
trate, at  least  to  the  satisfaction  of  Wendland,  that  temperature 
is  not  a  true  index  of  the  severity  of  the  disease. 

Similar  cases  have  been  recorded  by  Fisk,  of  Denver,  and  they 
are  represented  by  the  following  case: 

The  patient  was  a  male  with  a  negative  history,  except  that  he 

1  Vallin.  Archives  G^n^rales  de  M^d.,  November,  1893,  see  also  Liebermeister  and 
Hagenbach,  Aus  der  med.  Klin,  zu  Basel,  1869,  p.  9. 

2  Carter.     British  Medical  Journal,  October  10,  1908. 

3  Judd.     British  Medical  Journal,  December  3,  1904. 

*  Gerhardt.     Charitd  Annalen.  ''  Dreschfeld.     Practitioner,  1893. 

«  Fraentzel.     Ztsch.  f.  klin.  Med.,  1880. 

7  Wendland.     Deutsche  med.  Zeitung,  August  29,  1893. 


TJ'JMPJ'JUA'j'U/a'j  IN  riii<:  n/'JVJ-jj/U'hh  i)isi:.\sr:         77 

had  true  typhus  fever  jit  t^n  years.  On  ndmi ;  inn  Ik-  Ii.kI  ;i  tem- 
perature of  98.4°;  pulse,  H4;  resi)ir;i,ti()iis,  ^i);  llic  ton^nic  ua.s 
eoated,  showing  distinct  red  tif)  and  edge;  lie  had  an  apathetic 
appearance,  iind  (•()ni|)l;iined  of  licidnclic;  llie  pu[)il.s  were  dilated, 
there  were  tenderness  iuid  i;iMolin!;-  in  tlie  right  iliac;  fossa.  He 
still  had  constipation,  but  when  by  inedicalion  tlu;  bowels  were 
acted  upon,  the  fecal  matter  was  of  pea-soup  color  and  lifpiid. 
There  was  an  eruption  of  "rose  spots;"  the  spleen  was  normal. 
Upon  the  patient's  abdomen  and  back  were  found  numerous  pale 
blue  spots — taclie  hleudtre.  Close  inspection  showed  evidences  of 
pediculosis,  several  ova  being  attached  to  hairs. 

Later  it  was  noted  that  the  spleen  was  slightly  enlarged,  also 
that  the  palms  showed  the  characteristic  yellow  tint;  constipation 
still  existed,  but  the  pulse  was  not  so  rapid  as  on  admission. 

The  urine  was  yellow;  specific  gravity,  1020;  acid,  no  sugar, 
no  albumin. 

Later  the  headache  nearly  disappeared,  but  stupor  still  con- 
tinued.    The  diagnosis  was  afebrile  typhoid. 

Dreschfeld  also  mentions  this  form  of  apyrexial  typhoid  fever. 

The  accompanying  temperature-chart  (Fig.  14)  is  an  interesting 
illustration  of  this  type  of  case. 

Under  the  name  of  typhus  levissimus,  Griesinger  first  described 
forms  of  enteric  fever  in  which  the  febrile  movement  was  not  only 
very  mild,  but  in  which  the  symptoms  in  general  were  of  the  most 
moderate  form,  the  entire  course  of  the  disease  lasting  only  eight 
to  fourteen  days. 

Warren  Coleman^  has  recently  called  attention  to  certain  cases 
of  "short  duration  typhoid  fever,"  and  has  given  an  excellent 
review  of  the  literature.  He  found  that  in  the  earlier  days  short 
duration  typhoid  did  exist,  but  was  seldom  recognized.  Louis- 
saw  one  of  these  cases  wliich  perforated  and  came  to  autopsy. 
Wegelin,^  in  1854,  Griesinger,-*  in  1864,  jNIurcliison,'^  in  1873,  and 
Liebermeister,*'  in  1874,  described  cases  of  t^-phoid  fever  which  were 

1  Warren  Coleman.     Amer.  Jour.  Med.  Sci.,  June  1909. 

*  Louis.     Reclierches  sur  la  maladie  fi&vre  tj-phoide,  Paris.  1S41. 

3  Wegelin.     Zurich  Theses,  1S54.  ^  Griesinger.      Infktskrankh.   1S64. 

5  Murchison.     Continued  Fevers  of  Great  Britain,  1S73. 

8  Liebermeister.     Ziemssen's  Path.,  1S7-1. 


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TJ'JMP/'JU.ATi//a<:  IN  Till':  dhv I'li.oi'i:!)  ijisI'.asi:         70 

of  sliort  (liinilioii,  and  von  .liii-(^^ciiscii'  snid  lli;il  iIk-  uIi()Ic  (li«fu-y  of 
infc(;(:ive  discMScs  wus  imlciuiMc  if  llic  cxi  ,(<ii(c  of  luiMci'  UinuH 
could  not  1)0  sliovvii.  VViUi  die  ;id\;iiicc  iii;idc  \>y  die  inl  rod  i  if  lion  of 
the  Widal  reaction  iido  iiiedicine  die  mild  roiin.s  of  die  disease  liuve 
been  niueli  more  readily  diseovered.  1  .emoiiie,^  Catriji,''  an<l  J ioux^ 
demonstrated  that  the  mild  fevers  uliidi  were  commonly  called 
"embarrass  gaslrique  febrile'^  were  in  reah'ty  mild  typlioid  infec- 
tions. Woodruff''  proved  that  many  eases  of  so-called  inonntain 
fever  in  this  country  were  really  typhoid  fever,  and  l)rin;alski" 
and  Froseh^  discovered  many  eases  of  ty[)hoid  fever  among  the 
"simple  fevers"  of  Germany. 

Bates*  has  recorded  21  cases  of  short  duration  t\phoid  fever  at 
Panama,  and  Debrie"  and  Briggs^"  have  also  published  cases. 
Coleman  reports  24  cases  of  typhoid  fever  of  short  duration 
which  occurred  at  the  Bellevue  Hospital  in  the  five  years  previous 
to  1908.  The  febrile  period  in  9  of  the  24  cases  lasted  about  two 
weeks,  in  9  it  lasted  ten  days,  in  4  it  lasted  nine  days,  in  2  it  lasted 
five  and  six  days  respectively.  In  20  of  the  24  cases  there  was 
either  a  positive  blood  culture  or  positive  serum  reaction.  In 
the  remaining  four  cases  the  diagnosis  was  made  upon  chnical 
evidence,  it  having  been  impossible  to  study  the  cases  thoroughly. 

In  that  condition  known  as  "abortive  typhoid  fever,"  the 
severe  onset  and  high  fever  may  so  soon  be  followed  by  modera- 
tion and  signs  of  convalescence,  with  a  falling  temperatiu'e,  that 
the  course  of  the  temperature  may  be  most  aberrant  and  the  chart 
misleading  (Fig.  15). 

Here,  again,  however,  as  in  all  the  variations  of  temperature 
just  described,  the  physician  must  not  be  readily  led  into  a  diag- 
nosis of  an  aberrant  form  of  typhoid  fever  by  the  knowledge 
that  such  aberrant  forms  occur,  for  these  forms  are  so  infrequent 

1  Von  Jurgensen.     Volkmann's  Samml.  klin.  Vortr.  1870,  1  to  34. 
•  Lemoine.     Soc.  med.  d.  hop.  d.  Paris,  3s,  xiii,  669. 
3  Catrin.     Ibid.,  1896,  3s,  xiii,  698. 
<  Roux.     Ibid.,  1898,  xxxii,  102. 

°  Woodruff.     Jour.  Ainer.  Med.  Assoc,  1898,  xxx,  753. 
6  Drigalski.      Centralbl.  f.  Bakt.,  1903-04,  xxx^-,  1  Abt.,  776. 
">  Frosch.     Arch.  d.  mM.  et  phar.  mil.  1903,  xiii,  393. 
8  Bates.     Jour.  Amer.  Med.  Assoc,  1909,  lii,  1903. 

'  Debrie.     Arch,  de  la  direction  du  service  de  sante  du  14  Corps  d'Axmee,  1902. 
"•  Briggs.     Amer.  Med.,  1904,  viii,  639. 


80 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE 


as  to  be  curiosities,  and  are  so  rare  that  the  })n)hal)ihties  in  an 
obscure  case  are  against  their  presence.  Only  the  clear  and  un- 
doubted development  of  a  sufficient  number  of  symptoms  coupled, 
if  possible,  with  a  positive  reaction  with  the  Widal  test  and  with 
a  history  of  recent  possible  typhoid  infection,  should  cause  the 
physician  to  reach  a  diagnosis  of  these  types  of  enteric  fever. 

In  aged  persons  enteric  fever  is  usually  mild  in  its  temperature 
curves,  and  the  characteristic  febrile  movement  is  so  irregular  and 
distorted  as  to  be  devoid  of  much  diagnostic  value. 


Fio.  15 


F.     104° 
103° 

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101° 

100° 

99° 

98° 

97° 

Dny  of  Dis. 

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Abortive  typhoid  fever  ending  bj'  the  seventh  day,  and  by  crisis  instead  of  lysis. 

In  some  cases  the  fever  is  peculiar  in  that  it  fails  to  follow  the 
so-called  normal  rise  in  the  evening  and  slightly  lower  degree  in  the 
morning,  and  is  supplanted  by  an  inverse  type  in  which  the  morn- 
ing temperature  is  highest.  Su-ch  an  occurrence  took  place  in  the 
case  reported  to  us  by  Krusen,  which  is  quoted  in  Chapter  I. 

Chills. — In  this  connection,  too,  it  must  be  remembered  that  in 
some  cases  (not  many),  during  the  course  of  the  second  week,  the 
fever  develops  a  type  closely  resembling  that  seen  in  remittent 
malarial  fever.    According  to  many  writers  on  diseases  of  children, 


TEMPEIiATdUl':  IN   Till':   DHV  Hl/)l'i:i)    hi  Si:  ASH  SI 

this  form  oi  lyplioid  U-wr  is  \)\  no  niciiiis  cjnc  in  ihi.s  class  of 
patients.  Again,  as  tiiis  week  or  Ihc  lliiid  wed,  ends,  the  fel)rile 
movement  may  even  he  (Hsliiiclly  h'kc  that,  of  ;i  ii);il;iti;il  iii(r-i- 
mittent  without  there  heiiig  ;uiy  inahirial  iiifeefion.  Slr-iimpej  speaks 
of  such,  eases  in  which  distinct  reniitteiice  occurred,  and  of  ofhers 
in  which  die  fever  was  coinph'tely  iuterniident,  tiie  afternof^n 
tenij)erature  for  two  or  three  weeks  being  as  high  as  104°,  yet 
followed  by  morning  temperatures  at  the  normal  point,  and 
Pe})per  has  expressed  the  belief  that  these  great  variations  are 
in  part  the  result  of  marked  sepsis  and  intesliiud  nlceratioii. 
Thus  he  has  seen  as  much  as  7°  variation  occur  for  several 
days  in  succession.  Such  variations  should  never  be  considered 
curiosities  in  typhoid  fever,  but  should  stimulate  the  medical 
attendant  to  increased  endeavor  to  discover  a  septic  source  other 
than  the  intestinal  lesions  as,  for  example,  a  septic  gall-bladder  or 
kidney.  They  may  occur,  however,  in  cases  without  complicating 
diseases  or  lesions,  as  is  shown  in  Fig.  lo.  In  this  man's  case  the 
blood  was  examined  repeatedly  for  the  malarial  organism,  with 
negative  results,  and  there  was  no  history  of  exposure  to  it. 

Cases  of  this  type  are  also  recorded  by  Herringham,  who  dis- 
cusses these  temperature  variations  in  St.  Bartholomew's  Hospital 
Reports  for  1896.  In  one  of  these  a  woman,  aged  thirty-three 
years,  had  severe  rigors  followed  by  high  fever  on  the  evening 
of  the  twenty-third  and  the  morning  and  evening  of  the  twenty- 
fourth  day  of  the  disease.  These  rigors  were  followed  by  a  fall 
of  fever,  wliich  amounted  to  a  crisis,  and  speedy  convalescence 
ensued.  In  still  another  case  chills  and  fever  occurred  on  the 
thirty-first,  tliirty-fifth,  and  thirty-sixth  day  of  the  illness,  fol- 
lowed by  two  attacks  on  the  thirty-eighth  day.  These  were  in 
turn  followed  by  crisis  and  recovery.  In  the  other  cases  reported 
by  Herringham  a  rigor  occurred  in  one  during  the  acme  and  later 
during  lysis;  in  another  at  the  onset  of  lysis;  in  another  in  lysis; 
in  another  a  number  of  rigors  occm-red  in  acme  and  severe  rigors 
in  lysis,  probably  due  to  thrombosis.  Osier  has  also  reported  a 
case  of  this  type.^     Chiu'ch"  has  recorded  a  case  in  wliich  a  girl 

1  Osier.     Johns  Hopkins  Hospital  Reports,  1895,  No.  5. 
=  Church.     St.  Bartholomew's  Hospital  Reports,  1S96. 


82 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE 


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>> 

Q 

84  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

had  twenty-two  rigors  in  a  priniarv  attack  in  fourteen  days,  twenty- 
five  in  fifteen  days  in  a  first  relapse,  and  six  in  eleven  days  in  a 
second  relapse.     (See  page  47.) 

It  is  well  to  recall  the  fact  insisted  upon  by  no  less  an  authority 
than  Janeway/  that  the  use  of  the  coal-tar  products  in  the  course 
of  enteric  fever  may  have  a  chill-producing  effect,  and  it  is  well 
know  n  (hat  the  external  use  of  guaiacol  may  produce  severe  rigors. 

In  some  cases  presenting  such  rigors  there  is  present  a  true 
double  infection  of  typhoid  and  malarial  fever.     (See  farther  on.) 

There  are  a  number  of  conditions  which  result  in  producing  a 
marked  and  sudden  fall  of  temperature  during  the  periods  of  the 
fastigiinn  and  defervescence  aside  from  the  sudden  drop,  rarely 
seen,  in  which  the  fever  ends  by  crisis  instead  of  lysis,  the  patient 
passing  into  convalescence  at  once.  The  most  important  of  these 
causes,  both  because  of  their  degree  and  because  of  what  they  indi- 
cate, are  hemorrhage  from  the  bowel,  or,  if  it  be  profuse,  that  from 
any  other  part  of  the  body,  perforation  of  the  bowel  and  the  rigor 
preceding  a  complicating  infection  such  as  pneumonia,  the  begin- 
ning of  a  relapse  or  the  eft'ect  of  powerful  antipyretic  drugs.  Often 
great  falls  in  temperature  take  place  when  the  tyj^hoid  infection 
is  associated  with  malarial  infection,  as  already  intimated.  (See 
farther  on.) 

In  the  case  of  a  complicating  disease,  a  few  hours'  tlelay  in 
recognizing  its  presence  may  not  make  much  difference  to  the 
physician  or  patient;  but,  on  the  other  hand,  the  early  recognition 
of  hemorrhage  or  perforation  may  save  the  patient's  life.  The 
symptoms  of  perforation,  associated  with  the  fall  of  fever,  are 
prominent  and  will  be  considered  under  the  head  of  gastro-intes- 
tinal  accidents;  but  in  the  case  of  intestinal  hemorrhage,  the  fall 
may  occur  some  time,  it  may  be  several  hours,  before  the  appear- 
ance of  a  bloody  stool  enforces  the  belief  upon  the  nurse  that  hem- 
orrhage is  present.  For  this  reason  an  unexplained  marked  fall 
of  temperature  should  always  be  regarded  with  suspicion,  and  the 
appearance  of  the  next  stool  watched  with  interest.  The  pulse 
should  be  carefully  studied  for  signs  of  loss  of  blood,  and  the  facial 

'  Janeway.     Transactions  of  the  Association  of  American  Physicians,  1894. 


DIFFEUENTIAI.  DIAdSOSIS   rh'OM   (ri'lll:!;    \l M..\  I )l i:S       sr> 

expression  und  color  of  llic  li|)S  iind  (onij;iic  flosely  wjilflicd.  I)'  the 
patient  is  conscious  and  ciij)iU)ie  ol"  f^iviii^^  exfircssion  (o  his  sensa- 
tions, he  may  comphiin  of  a  sensalicjn  of  fiiinlness  or  of  sirjkin^; 
or  if  the  hemorrhage  is  very  profuse,  the  patient  may  pa,s.s  raf)idly 
into  a  state  of  colhipse  or  shock,  owing  to  the  extravasation  of 
Mood  into  the  small  and  large  howcl,  dying  almost  sinniltaneously 
with  the  gnsii  of  hiood  from  die  reel um.  Thus  we  have  seen  a  case 
apparently  passing  safely  through  a  moderately  severe  attack  of 
enteric  fever  suddenly  develop  the  symptoms  named,  present  all 
signs  of  marked  exsanguination,  and  then  pass  into  the  bed  an 
enormous  volume  of  h;df-elo((ed  l)l()od,  which  extended  frf>m  the 
anus  to  the  heels,  at  the  same  moment  developing  gasping  respira- 
tion, profound  syncope,  and  seeming  to  be  ///  arliculo  mortis. 
So,  too,  we  have  seen  hypodermoclysis,  actively  employed,  result  in 
the  recovery  of  patients  so  greatly  exsanguinated  that  death 
seemed  inevitable. 

In  some  instances,  however,  even  profuse  intestinal  hemorrhage 
recurring  again  and  again,  fails  to  cause  a  very  great  fall  in  the 
temperature,  or  keeps  it  low  Ijut  for  a  short  time. 

Sometimes  well-developed  signs  of  collapse  appear  in  the  course 
of  typhoid  fever  without  indicating  any  serious  accident  in  the 
course  of  the  disease  which  could  produce  these  symptoms.  In 
this  state  the  patient  develops  a  rapid  pulse,  shallow  respirations, 
pallor  and  lividity,  accompanied,  it  may  be,  by  a  rigor.  There  is 
usually  a  marked  fall  of  temperature.  Herringham^  asserts  that 
these  symptoms  have  no  eflFect  on  the  prognosis,  and  that  treat- 
ment is  practically  unavailing.  On  the  other  hand,  they  may 
mean  that  the  patient  is  in  grave  danger,  as  has  been  pointed  out 
by  Landouzy  and  Siredey.^  (See  circulatory  changes  in  the  well- 
developed  and  convalescing  stages  of  the  disease.) 

Dijfferential  Diagnosis  from  Other  Maladies. — How  far  con- 
stant fever  occurring  day  after  day,  and  associated  with  mani- 
festations of  general  loss  of  strength  and  debihty  can  be  rehed 
upon  in  the  diagnosis  of  typhoid  fever,  is  hard  to  determine. 
Certain  it  is,  that  if  a  physician  makes  a  diagnosis  of  enteric 

1  Herringliam.     St.  Bartholomew's  Hospital  Reports,  1S96. 
-  Landouzy  and  Siredey.     Re\Tie  de  M^deeine,  18S7,  p.  S04. 


80  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

fever  upon  these  symptoms  alone,  Avithout  hearing  in  mind  the  fact 
that  simihir  comhtions  are  equally  well  developed  under  other  forms 
of  infection,  he  will  find  himself  in  error  in  not  a  few  instances. 
Chief  among  these  may  he  mentioned  tuberculosis  of  the  lungs  or 
peritoneum,  miliary  tuberculosis,  that  form  of  influenza  in  which 
the  chief  symptoms  are  abdominal,  cases  of  ulcerative  endocarditis, 
lymphosarcoma  and  carcinoma  of  the  liver,  septicfemia  and  pyaemia, 
malaria,  rare  forms  of  scarlet  fever  and  meningitis,  and  those  of 
cliolecystitis  with  ulceration,  as  from  impacted  gallstones.  It  must 
not  be  forgotten,  too,  that  syphilitic  fever  may  in  very  susceptible 
persons  resemble  typhoid  infection.  The  febrile  movement,  rose 
rash,  if  it  be  scanty,  malaise,  and  signs  of  general  infection  may 
readily  mislead  the  physician.  Again,  in  the  more  advanced  stage 
(tertiary)  of  sypliilis  prolonged  low  septic  fever  may  be  present. 

Finally,  let  it  not  be  forgotten  that  trichiniasis^  may  resemble 
t}^hoid  fever,  for  in  it  we  have  fever,  pains  in  the  limbs  and  back, 
headache,  stupor,  and  nausea,  with  pain  in  the  belly  and  diarrhoea. 

Points  in  differential  diagnosis  in  this  condition  are  the  pres- 
ence of  leulvocytosis  (particularly  in  eosinophiles),  and  its  absence 
in  typhoid  fever,  and  puffiness  of  the  bridge  of  the  nose  and  about 
the  eyes  is  seen  in  trichiniasis. 

Not  only  may  the  fever  of  these  states  be  moderate  and  pro- 
longed and  the  evidences  of  asthenia  marked,  but  enlargement  of 
the  spleen,  diarrhoea,  and  tympanites  may  be  present.  The  diffi- 
culties in  differential  diagnosis  in  cases  of  suspected  gall-bladder 
disease  are  increased  by  the  fact  that  such  disease  often  has  its 
origin  in  an  old  infection  of  the  gall-bladder  due  to  an  attack  of 
typhoid  fever  months  or  years  before,  the  bacillus  of  Eberth  being 
present  in  this  viscus  during  the  entire  interval,  or  in  other  cases  it 
invades  the  gall-bladder  at  the  onset  of  the  infection  of  the  entire 
body,  and  so  emphasizes  the  hepatic  symptoms.  I'urther  than  this, 
cases  which  have  previously  had  enteric  fever  may  also  give  the 
Widal  test,  although  the  immediate  cause  of  the  attack  may  be 
localized  in  the  manner  named.  These  forms  of  infection  wall  be 
considered  later  on. 

Reference  has  already  been  made  to  the  possibility  of  the  febrile 

1  Osier.     American  Journal  of  the  Medical  Sciences,  March,  1899. 


D/FF/'Jh'h'N'J'/A/j    blACNOSIS   I'ltOM    O'/'l//:/,'   M M.\  I >l l':S       S? 

movcTnont  re.seiii})liii^  lliiil,  ol'  iiia,lari;il  \(-\('V.  In  oiim-  cases  Uiis 
iiircction  is  truly  j)r('S('ii(:,  l)iit  in  others  tlic  (ciiipciiiiuic-cliurt  is 
that  of  ail  Irrco'iilai'  typlioid  fever. 

These  facts  hi'in^  iis  face  to  I'aee  with  a  (liseiission  f»f'  a  siihjeet 
about  which  great  diversity  of  opinion  exists,  and  has  existed  for 
years,  namely,  the  cjuestion  of  that  condition  which  has  been 
called  " typhonialarial  fever."  At  the  f)resent  time  il  may  be 
asserted  as  a  fact  that  a  separate  disease  entity  of  this  c-haracter 
does  not  exist.  Recent  discoveries  in  the  natural  history  fjf  these 
diseases,  particularly  the  recognition  of  the  malarial  germ,  the  use 
of  the  Widal  test,  and  the  finding  of  the  bacillus  of  Eberth  in 
the  blood  have  enabled  us  to  make  an  absolute  diagnosis  in  cases 
in  which  it  has  heretofore  been  impossible. 

There  is  no  doubt  whatever  that  uncomplicated  typhoid  infection 
may  result  in  the  production  of  a  fever  which  closely  follows  the 
remittent  and  intermittent  malarial  types.  This  is  often  asso- 
ciated with  so  much  gastric  disturbance  and  so  lacking  in  the 
more  prominent  typhoid  symptoms  that  the  picture  of  malarial 
fever  seems  clear,  while  the  picture  of  typhoid  fever  is  clouded. 
(See  also  chapter  on  diseases  which  resemble  typhoid  fever.) 
Again,  there  can  be  no  doubt  that  cases  of  true  malarial  infection 
occur  in  which  the  symptoms  so  closely  resemble  those  of  typhoid 
fever  that  a  purely  clinical  diagnosis  is  almost  impossible,  particu- 
larly if  an  epidemic  of  typhoid  fever  is  in  full  swing  at  the  time. 

As  already  shown,  there  can  be  no  doubt  that  mild  grades  of 
typhoid  infection  take  place  in  which  the  only  symptom  is  a  fever 
which  runs  a  moderate  com"se  and  is  accompanied  by  a  certain 
degree  of  general  debility.  These  forms  often  begin  rather 
abruptly,  with  a  slight  chill,  or  gradually  the  patient  feels  less  and 
less  well  until  he  takes  to  his  bed.  Such  cases  are  characterized 
by  well-marked  remissions,  it  may  be,  and  suffer  from  somewhat 
indefinite  symptoms  difficult  of  classification.  They  do  not  respond 
to  quinine,  nor  do  they  show  any  typhoid  symptoms  other  than 
those  named.  The  diagnosis  arrived  at  will  depend  largely  upon 
whether  the  physician  is  practising  in  the  North  or  the  South,  and 
is  treating  many  cases  of  enteric  fever  or  many  of  remittent  fever, 
unless  he  is  skilful  with  his  microscope,  in  which  case  a  careful 


SS  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

blood  examination  or  the  "Widal  reaction  of  typhoid  fever  will,  in 
a  majority  of  cases,  at  some  time  settle  the  diagnosis  for  liim,  or 
an  autopsy  will  show  typhoid  lesions. 

Or,  on  tlie  other  hand,  he  may  find  the  malarial  organism  in 
the  blood,  which  will  prove  that  this  infection  is  present,  although 
it  will  not  exclude  typhoid  fever,  just  as  the  Widal  test  will  not 
exclude  malarial  infection. 

Atkinson  has  well  described  that  form  of  typhoid  fever  resem- 
bling malarial  fever  of  the  remittent  type  in  the  following  words: 

"From  beginning  to  end  the  patient  may  develop  no  symptom 
that  could  not  belong  to  this  disorder  (malarial  fever),  except  the 
persistence  of  fever  under  strongly  antimalarial  treatment  and  the 
occasional  occurrence  of  circumstances  that  point  to  a  typhoid 
origin.  There  is  no  intellectual  cloudiness  or  hebetude  of  expres- 
sion. Sleep  is  but  slightly  disturbed.  The  tongue  remains  moist, 
and  coated  A^ith  a  thin  whitish  or  yellowish  fur;  the  appetite  per- 
sists very  often  in  some  degree.  There  is  almost  never  epistaxis. 
Constipation  is  commonly  observed,  diarrhoea  very  rarely.  There 
are  no  bloody  stools,  no  tympanites,  no  iliac  tenderness  or  gurgling. 
Rose  spots  are  much  more  often  absent  than  present.  The  patient 
can  be  restrained  in  bed  with  difficulty  or  under  protest.  Slight 
enlargement  of  the  spleen  may  occasionally  be  detected,  but  is 
more  frequently  not  observed.  More  severe  cases,  beginning  more 
or  less  abruptly,  develop  primarily  the  symptoms  of  remittent  fever, 
and  diagnostic  doubts  only  arise  when  the  absolute  resistance  to 
antiperiodic  treatment  and  the  gradual  appearance  of  ty})hoid 
symptoms  excite  suspicions  of  the  incorrectness  of  the  original 
diagnosis." 

Finally,  there  can  also  be  no  doubt  that  it  is  possible  for  the 
patient  to  have  a  double  infection  with  the  bacillus  of  Eberth  and 
the  Plasmodium  of  Laveran,  in  which  case,  however,  the  malarial 
manifestations  are  usually  dwarfed  by  the  typhoid  poison,  and 
only  are  marked  at  the  onset  of  the  enteric  fever  and  at  its  termi- 
nation. To  this  mixed  infection  the  term  " typhomalarial  fever" 
may  be  correcdy  applied  to  indicate  not  a  separate  disease,  but  a 
double  infection.  Etymologically,  this  term  might  also  be  used 
to  define  a  condition  of  malarial  fever  in  which,  because  of  pro- 


COURSE  OF  TIII<:  FKV/'JJi  IN   h'hLA'I'IOS   VO   I'UOCSOHIH     89 

found  (lcl)ili(y,  the  piiticnt  is  in  a  typlioid  state — that  i.s,  in  a 
condition  of  whi(;h  tyj)lioi(l  fever  i.s  a  (y|)f'.  The  term  "  typlio- 
malarial  fever"  shouhl  he  discarded,  or  nmitcd  in  its  use  to  the 
dou})le  infection  just  described. 

Jolmston  has  well  said,  "As  at  present  employed,  the  term 
tyi)lionialarial  fever  has  no  determined  meaning,  leads  to  confu- 
sion and  misunderstanding,  is  a  cover  for  uncertainty  and  ignorance, 
and  should  he  discouraged  and  ahandoned." 

(For  a  description  of  infectious  processes  complicating  (yphoifl 
fever,  see  text  farther  on.) 

The  Course  of  the  Fever  in  Relation  to  Prognosis. — It  ha.s 
already  been  pointed  out  that  fever  of  sudden  onset,  soon  followed 
by  a  fall  or  affected  by  marked  remissions  during  the  stage  of 
onset,  is  a  favorable  rather  than  unfavorable  omen.  A  some- 
what similar  statement  holds  true  in  regard  to  the  fever  of  the 
well-developed  disease  in  which  the  presence  of  persistently  high 
morning  and  evening  temperature,  the  variation  Ijetween  the  two 
being  but  slight,  possesses  an  evil  significance,  while,  on  the  other 
hand,  marked  differences  between  these  points  are  considered  of 
good  omen.  Tliis  is  so  because  remissions  indicate  that  the  infec- 
tion is  not  virulent,  or  resistance  is  adequate,  and  because  remissions 
permit  the  body  to  make  repairs  to  enable  it  to  stand  another  rise, 
whereas  the  constant  maintenance  of  high  fever  seriously  impairs 
the  vitality  of  the  tissues.  This  temporary  reduction  of  fever  is 
probably  one  of  the  ^^■ays  in  which  the  cold  bath  does  good. 

In  regard  to  the  prognostic  value  of  high  temperatures  we  find 
considerable  unanimity  of  opinion.  Liebermeister,  in  studying 
400  cases,  found  that  of  those  whose  temperatm-es  rose  to  104° 
or  more,  9.6  per  cent,  died;  of  those  whose  fever  exceeded  this 
degree,  29.1  per  cent,  died;  and  of  those  whose  axillary  tempera- 
ture exceeded  105.S°,  more  than  half  died.  Fiedler^  found  that 
when  the  temperature  reached  106°  more  than  half  died,  and 
Wunderlich  states  that  at  106.1°  the  danger  is  considerable,  at 
107°  the  deaths  are  almost  t\\ice  as  numerous  as  the  recoveries, 
and  at  107.2°  and  over  recovery  is  rare.  Concerning  the  influence 
of  high  morning  temperatures,  Fiedler  says  that  practically  all 

1  Fiedler.     Deutsehes  Arch,  fur  klin.  Medicin.  Band  i,  p.  534. 


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105° 
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Day  of  Dis. 

Pulse 

Resp. 

COdUSJ'J  OF   'ri/l'J   /-'ATA'/i'   /iV    KHLATIOS    7  0    I' l{< ICSOSIS      O.'j 

[)a,l,i(>n(:,s  died  wliosc  iiiorniiiii;  r('V(,'r  rose  Ut  ]()i\.2,^  iiiid  lluit  more 
tliiui  liiiH"  (lied  il"  dicir  iiioniiiifr  Fever  re;ielied,  il"  only  (»iiee,  \{]').\'^. 

In  the  Miiidslone'  epidenn'e  only  one  de;idi  oceniied  in  81 
cases,  the  teni])eriitnre  of  which  reaehed  less  than  KJJ'^,  whereas 
nine  deaths  occurred  in  patients  who  had  fever  at  some  time  above 
104°.    A  case  is  recorded  of  recovery  after  a  tpmj)erature  of  1  \{)°? 

While  acute  hyperpyrexia  may  l)e  an  evil  omen  in  enlerie  fever, 
long-continued,  moderately  high  fever  is,  pei"lia|)S,  more  harmful. 

In  the  Boylston  Prize  l^lssay  of  Harvard  University  lor  ]Sf)0,  on 
^'Fever,"  the  senior  author  used  these  words  in  speaking  of  this 
subject: 

"Closely  allied  to  this  question  of  hyperpyrexia  is  that  which 
asks  us  to  define  what  we  mean  by  hyperpyrexia.  As  given  in 
most  works  on  fever,  this  term  is  applied  to  any  state  in  which 
the  temperature  reaches  100°  or  107°;  but  in  reality  the  figures 
have  little  to  do,  except  in  an  indirect  way,  with  what  the  student 
or  physician  wishes  to  know-.  A  temperature  of  106°  in  a  young 
healthy  man  suffering  from  an  acute  attack  of  some  short-lived 
disease  does  not  mean  very  great  danger;  but  a  temperature  of 
103°,  day  after  day  in  typhoid  fever,  does  mean  danger,  and  must 
be  carefully  attended  to.  In  simple  continued  fever  106°  is  a 
hyperpyrexia;  in  typhoid,  or  other  low  fever,  103°  is  a  hyper- 
pyrexia. The  question  is  not  one  of  actual  degrees  Falu-enheit,  but 
rather  as  to  whether  the  temperature  present  is  doing  any  harm." 

Very  great  differences  are  to  be  found  in  different  patients  in 
respect  to  the  persistency  of  liigh  fever  under  the  application  of 
hydrotherapy.  In  some  instances  active  bathing  serves  to  reduce 
the  fever  but  slightly;  in  others,  moderate  measures  produce  a 
marked  effect.  As  an  illustration  of  the  great  fall  produced  by 
sponging  with  ice-water  for  twenty  minutes,  with  active  friction, 
leference  may  be  had  to  the  above  chart  (Fig.  18),  in  wliich 
it  is  seen  that  as  great  a  fall  as  8°  occm'red.  One  is  tempted  to 
inquire  how  low  it  would  have  fallen  had  the  routine  method  of 
plunging  every  patient  sick  "uith  typhoid  fever  been  institvued. 
Yet  the  patient  was  an  unusually  heavily  built,  stalwart  youth  of 

1  Poole.     Guy's  Hospital  Reports,  1S9S.     Wronglj-  labelled  on  cover,  1S96. 

2  St.  Thomas'  Hospital  Reports,  1S95,  p.  248. 


94  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

twenty  years,  well  nourished,  and  in  good  condition  for  bathing. 
Further,  he  came  under  care  hy  the  thirtl  day  of  his  iUness. 

Respiratory  System  in  the  Developed  Stage  of  the  Disease. 
— ^^riie  respiratory  functions  of  patients  sufi'ering  from  tyj)hoid  fever 
are  not  materially  disturbed  unless  some  complicating  affection  of 
the  lungs  or  nearby  organs  develop.  Beyond  a  slight  (juickening 
of  the  respirations,  varying  from  two  to  eight  a  minute,  as  the 
result  of  the  fever,  they  maintain  an  even  rhythm.  The  develop- 
ment, therefore,  of  rapid  or  noisy  breathing  is  indicative  of  some 
pulmonary,  cardiac,  or  renal  complication,  and  deserves  close 
scrutiny  and  study. 

Before  discussing  the  graver  respiratory  complications  of  thi.s 
malady,  there  are,  however,  several  minor  facts  in  connection  with 
this  part  of  the  body  which  deserve  notice.  One  of  the  first  of 
these  is  the  curious  fact  that  coryza  is  almost  never  met  with  in 
typhoid  fever  in  any  of  its  stages,  and  its  presence  with  other 
signs  pointing  to  enteric  fever  stands  against  the  presence  of  this 
malady. 

Epistaxis. — Another  point  of  interest  is  the  frequency  of  epistaxis,. 
which  is  chiefly  met  with  in  the  first  week  of  the  disease,  as  already 
pointed  out,  and  which  is  also  seen  quite  commonly  later  on,  prob- 
ably being  produced  in  most  instances  by  the  patient  picking 
the  nose  to  remove  crusts,  while  in  the  early  stages  it  is  a  means 
that  the  system  takes  for  relieving  the  frontal  headache  and  con- 
gestion which  are  so  common  at  that  time.  J.  M.  Da  Costa^  pre- 
sented in  a  clinic  two  patients  who  had  this  symptom  late  in  the 
disease.  The  first  patient  had  been  ill  twenty-nine  days,  and  his 
temperature  had  reached  normal.  The  epistaxis  was  violent,  last- 
ing half  an  hour,  and  several  ounces  of  blood  w^ere  lost.  Cerebral 
symptoms  were  relieved,  and  the  man  made  good  progress  after- 
ward. The  second  patient  had  profuse  epistaxis  during  the  fourth 
week  of  the  disease,  after  symptoms  of  typhoid  fever  had  practi- 
cally ceased.  Late  epistaxis  is  more  apt  to  occur,  in  Da  Costa's 
opinion,  after  severe  cerebral  symptoms,  wliich  are  thus  relieved. 
In  still  other  cases  the  hemorrhage  from  the  nose  is  part  of  the 
manifestation  of  a  general  hemorrhagic  diathesis.     Very  rarely  is 

1  J.  M.  Da  Costa.     Medical  Fortnightly,  February  1,  1899. 


77//';  lU'.si'iiiATOL'V  s)',sti':m  in  tiih  I)I':v i:i.()I-i:i)  staci-:      ().-> 

the  symptojii  excessive  v\Hn\\i\\  l,o  rc(|iiiic  ;i'livc  iiilcil'eicnce,  uikJ 
still  more  rarely  does  it  cause  death.  Thus,  oiil  of  1420  cases  seen 
by  Liebermeister,  epistaxis  look  phicc  in  107  cases,  l)ut  death 
occurred  from  this  cause  in  only  two,  and  this  is  probably  a  high 
percentage.     Jn  Osier's  series  of  .S20  ca.ses  epistaxis  occurrcfj  in  1S2. 

There  have  occasionally  been  seen  cases  of  typhoid  r(\(i-  cDm- 
j)licated  with  Ludwig's  angina.  Murray^  rejjorts  such  a  case 
which  caused  (X'dema  of  the  glottis,  and  Robertson''  and  Biedert 
report  the  development  of  an  angina  which  proved  fatal  ten  hours 
after  the  onset  of  the  complication. 

Laryngitis. — I^aryngeal  inflammation  as  a  comy)lication  of 
typhoid  fever  was  first  observed  and  reported  by  Bayle.^  He  re- 
ported two  cases,  both  fatal.  One  died  after  an  unsuccessful  attempt 
at  relief  by  tracheotomy,  the  other  died  without  any  effort  at 
operative  interference.  An  occasional  case  w^as  reported  from  1808 
on  in  the  French  literature,  and  in  1818  Joseph  Frank,  of  Leipzig 
(quoted  by  Rieser),  reported  two  cases  based  upon  the  autopsy  find- 
ings of  Pommers  and  Horn.  Louis,  in  1829,  reported  four  cases 
with  autopsy  findings,  and  in  the  same  year  Pockel,  a  German 
military  surgeon,  performed  the  second  tracheotomy  in  typhoid 
laryngitis.  The  operation  gave  immediate  relief  and  the  patient 
recovered.  This  was  the  first  successful  tracheotomy  performed 
for  this  condition. 

Rokitansky,  of  Vienna,  in  1842,  was  the  first  pathologist  to  care- 
fully study  the  laryngeal  complications  of  typhoid  fever.  The 
earlier  pathologists,  although  they  recognized  the  lesions,  were  of 
the  opinion  that  they  were  due  to  secondary  infections.  Roki- 
tansky, however,  referred  to  the  lesions  as  the  result  of  the  effect 
of  the  typhoid  poison  in  every  way  analogous  to  the  developments 
in  the  intestinal  mucosa. 

W.  W.  Keen,^  of  Philadelphia,  in  1876,  summarized  the  htera- 
ture  relating  to  this  condition  and  was  able  to  collect  169  cases. 
These  cases  he  classified  clinically  and  pathologically,  giving  the 
most  complete  consideration  of  the  subject  wliich  had  appeared  up 
to   that  date.     In   1884  Luning,   without  knowledge   of  Keen's 

1  Murray.     British  Medical  Journal,  September  13,  1902. 

-  Robertson.     Amer.  Jour.  Med.  Sci.,  January  1902. 

5  Bayle.     Societe  de  Medecine  de  Paris,  ISOS.  *  Keen's  Toner  Lectures. 


96  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

publication,  reviewed  the  literature,  collecting  192  cases  and  adding 
14  from  his  own  knowledge.  In  1896  Keen's  classical  publication 
"The  Surgical  Complications  of  Typhoid  Fever"  completed  the 
author's  earlier  work  and  added  to  the  number  of  cases  those 
reported  by  Luning  as  well  as  such  cases  as  had  been  subsequently 
reported,  his  total  being  221  cases. 

Since  this  last  review  Homer  Dupuy,^  in  1903,  reported  one  case 
and  added  34  collected  ones,  while  llieser,"'  in  a  more  recent  report, 
has  added  2  personal  cases  and  collated  the  recent  literature,  bring- 
ing the  total  number  of  cases  reported  to  281. 

A  glance  at  the  numl)er  of  cases  reported  will  convince  anyone 
that  the  complications  affecting  the  larynx  during  typhoid  fever 
are  not  as  rare  as  we  once  thought,  and  it  is  somewhat  difficult  to 
understand  the  rarity  of  the  laryngeal  lesion  in  certain  series  of 
cases.  Schulz,  who  analyzed  4094  cases  of  typhoid  fever  which 
occurred  in  Homburg  in  1886  and  1887,  does  not  record  any  cases 
of  perichondritis  of  the  larynx,  and  Jacob  does  not  mention  this 
complication.  On  the  other  hand,  Hoffmann  found  laryngeal  ulcers 
in  28  cases  out  of  250  autopsies  upon  typhoid  fever  subjects,  and 
Griesinger  found  them  in  26  per  cent,  of  the  cases  that  died. 

These  statistics  bear  out  our  belief  that  in  the  severe  forms  of 
tvphoid  fever  resulting  in  death,  laryngeal  lesions  are  commonly 
present.  Every  writer  who  has  made  a  special  study  of  this 
complication  is  impressed  with  the  fact  that  pathological  involve- 
ment of  the  larynx  is  much  more  frecjuent  than  is  clinically 
recognized. 

In  regard  to  the  cause  of  laryngeal  involvement,  it  may  be  that  the 
friction  and  irritation  produced  by  the  acts  of  phonation,  swallow- 
ing and  coughing  act  upon  a  surface  wliich  is  already  suffering  from 
the  effects  of  the  typhoid  toxemia,  but  there  can  be  no  question 
that  the  specific  organism  of  the  disease  is  really  accountable  for 
the  lesions.  Schulz,^  Williams,''  and  Weil"^  have  been  able  to  isolate 
the  germ  in  sections  from  the  larynx,  and  grow  them  in  pure  culture, 

1  Dupuy.     New  Orleans  Medical  and  Surgical  Magazine,  1903. 

2  Rieser.     American  Journal  of  the  Medical  Sciences,  February,  1908. 
'  Schulz.     Berliner  klin.  Wochenblatter,  Band  xxxv. 

*  Williams.     Diseases  of  the  Upper  Respiratory  Tract. 

^  Weil.     Transactions  of  the  New  York  Pathological  Society,  1905. 


27/Zi'  JiJ'JSi'iKATOh'.)'  s)'S'/'/':m  IN  Tiih:  i)h:v i-:i.()i' i:ij  ,<'r.\',i.     w-j 

and  ITcrlx'rt  and  Ivii^biruin,'  jis  well  us  -Juck.sfjii,"  f;iiltiv;ilf;ri  tlic 
specific  or<^anisin  in  ])nr(;  (aniline  from  the  })u.s  of  a  [)criclif>n(irial 
laryngeal  abscess.  Thermic  influences  may  also  exert  ;i  predi.s- 
])()sing  inflnence. 

J)ittrich''  asserts  that  the  innannnatory  process  is  (hic  lo  the 
dorsal  position  of  the  ])atient,  and  is  more  j)arlicnlMrly  dne  to  the 
pressure  of  the  laryngeal  cartilages,  piirliciihnly  fhc  cricoid  rings, 
against  the  vertehral  colnnm.  As  the  resnit  of  this  pressure, 
Dittrich  believes  that  the  vitality  of  the  cartilages  is  iiii|)aired  and 
microorganisms  find  this  damaged  tissue  vulneraljlc  This  theory 
seems  to  us  of  little  value. 

In  an  inaugural  thesis  uj)on  ulcerations  of  the  larynx  during 
typhoid  fever,  Gruder'*  describes  three  types.  In  one  the  specific 
ulcers  occur  simultaneously  with  those  in  the  bowel.  In  the 
second  class  there  are  simple  catarrhal  manifestations  with  a 
tendency  to  ulceration.  Both  of  these  classes  involve  the  posterior 
wall  of  the  larynx  on  the  aryepiglottic  fold.  The  third  class 
described  by  Gruder  is  one  in  which  ulcers  form  at  the  margin  of 
the  epiglottis.     These  latter  ulcers  usually  occur  singly. 

Keen,  in  1876,  classified  the  lesions  as  inflammatory  or  submu- 
cous laryngitis,  ulcerative  laryngitis,  and  laryngeal  perichondritis, 
none  of  which  forms  can  be  sharply  outlined,  they  at  times  over- 
lapping one  another.  The  frequency  of  its  occurrence  is  given  by 
Luning  as  12  per  cent,  basing  liis  statistics  on  1032  autopsies. 
Of  the  2C0O  Munich  cases,  10.7  per  cent,  showed  laryngeal  ulcers, 
and  Baer,  in  89  autopsies,  found  laryngeal  lesions  in  3.4  per  cent, 
of  them.  Liining  divided  the  12  per  cent,  of  laryngeal  lesions 
into  1.5  per  cent,  of  simple  or  submucous  laryngitis,  and  a 
little  over  5  per  cent,  each  of  ulcerative  larvnoitis  and  larvngeal 
perichondritis. 

In  over  40CO  autopsies  collected  by  Liining  the  posterior  laryn- 
geal wall  at  the  insertion  of  the  vocal  cords,  involving  the  cricoid 
cartilage,  was  the  seat  of  the  lesion  in  60  per  cent,  of  cases.  The 
arytenoid   cartilages   and  interspace   were   next   most  frequently 

'  Herbert  and  Liebman.     Chicago  Medical  Recorder,  September,  1905. 
^  Jackson.     American  Journal  of  the  Medical  Sciences,  Xovember,  1905. 
^  Dittrich.     Handbuch  der  Special  Path,  und  Ther.,  Band  i.  p.  311. 
*  Gruder.     Centralblatt  f.  Bacteriol.  and  Parasit..  February  17,  1S91. 

7 


98  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

involved.  The  arvteno-epi(i;lotti(lean  folds,  epiglottis,  and  the 
thyroid  cartilages  being  ali'eoted  in  the  order  named. 

Clievalier  Jackson,  in  his  series  of  360  laryngological  examina- 
tions in  patients  ill  of  typhoid  fever,  found  ulcers  present  in  GS 
cases,  affecting  the  epiglottis  forty-two  times,  aryteno-epiglottidean 
folds  22  times,  interarytenoid  space  18  times,  and  arytenoid  car- 
tilage 10  times. 

Basing  his  views  upon  his  statistics,  and  in  particular  upon  four- 
teen original  cases,  Liining^  gives  the  following  graphic  word-picture 
of  the  condition: 

"Physician  and  patient  together  rejoice  over  the  daily  progress 
toward  convalescence;  of  the  still  slight  but  persistent  trouble  in 
the  throat,  scarcely  a  word  is  said,  until  all  at  once — an  expo- 
sure to  cold,  a  little  walk,  is  then  usually  blamed  for  it — the 
hoarseness  increases,  and  swallowing  becomes  markedly  })ainful. 
The  picture  now  quickly  alters.  Soon,  often  witliin  a  few  hours, 
come  dyspnoea  and  suffocating  attacks.  Sometimes  even  during 
the  very  jfirst  day  the  anxious  scene  of  laryngeal  stenosis  sets  in, 
with  stridor,  inspiratory  depression  of  the  neck  and  chest  wall — 
the  unrest  of  despair,  a  struggle  ^dth  death.  The  face  becomes 
livid;  the  respiration  becomes  rapid,  wearisome;  the  auxiliary 
muscles  of  respiration  are  all  called  into  play;  sometimes  the 
respirations  are  prolonged  and  noisy.  The  patient  can  find  no 
rest;  the  dyspnoea  even  prevents  the  taking  of  nourishment;  the 
expectoration  of  the  increasing  mucus  becomes  imperfect;  soon 
attacks  of  suffocation  recur.  Either  a  tracheotomy  must  now  be 
done  immediately,  or  the  patient,  if  he  is  weak,  may  choke  to 
death,  even  in  the  first  attack.  More  commonly,  however,  the 
attack  subsides,  and  a  slight  improvement  with  a  short  sleep  will 
ensue.  Expectoration  of  bloody  mucus,  masses  of  pus,  and,  in 
some  cases,  even  of  pieces  of  cartilage,  diminish  the  symptoms, 
and  show  at  the  same  time  that  the  real  cause  of  the  dyspnoea  is 
not  a  catarrhal  oedema  or  dropsical  swelling,  but  a  destructive 
ulceration,  even  of  the  cartilages.  Often,  also,  there  is  severe 
fever.  Thus  pass  on,  it  may  be,  even  days  and  weeks,  easy 
breathing  alternating  with  the  suffocative  attacks.     The  alterna- 

'  Luning.     Archiv  fur  klin.  Cliirurgie,  1884,  vol.  xxx,  p.  225. 


Tiiic  u/':sr/h'AT(jh',y  s)'st/':m  in  th/'J  dkvI'Ii.oi'i:!)  sta(;i-:     <i9 

tivo  is  only  ;i  firiully  fatal  attack  of  ,siin'()<-;ilif)ii,  or'  ;i  l;i(c  palliative 
traclu'otoiny  with  all  its  uiic-<'r(;iiiitics.     .  .     IT  one  will  road 

the  reports  of  cases  of  death  frr)iii  siifl'ociilion  uitlioiit  operation 
(52  cases,  49  deaths),  he  will  (ind  (luit,  nlmosi  widioul  exception, 
sufToeation  occurred  early  and  (juickly,  Ixil'ore  either  physiei;in  or 
patient  had  even  thought  of  tracheotomy. 

"This  is  the  picture  in  cases  of  perichondritis.  If  tlie  |)atient 
is  in  the  stage  of  typhoid  stupor,  when  the  iileer;ilion  is  accompa- 
nied with  acute  suj)])nration  and  swelling;  vvhieh  may  lead  to 
destruction  of  the  eartilaoes,  the  initial  sym[)toms  of  the  threat- 
ening danger  may  escape  us  entirely  in  spite  of  careful  observa- 
tion. ...  In  these  cases  the  objective  signs  of  laryngeal 
stenosis,  on  w^hich  we  usually  depend,  are  much  le.ss  marked; 
stridor,  movements  of  the  larynx,  inspiratory  depression,  action 
of  the  auxiliary  inspiratory  muscles — in  short,  everything  by  which, 
in  the  healthy,  we  make  the  diagnosis  of  narrowing  of  the  air 
passages  is,  in  the  vita  minima  of  the  weakened  patient,  far  less 
outspoken,  and  easily  deceives  us  as  to  the  degree  of  the  danger  of 
suffocation.  The  striking  suffocative  attacks,  wdth  arrest  of  respi- 
ration, so  alarming  even  to  the  lay  observer,  are  less  noticeable, 
since  the  struggle  of  the  patient  with  the  mechanical  obstruction 
quickly  fails  or  is  quickly  abandoned.  The  condition  passes  into 
a  death  agony  with  oedema  of  the  lungs,  without  the  stenosis 
seeming  to  have  reached  a  threatening  degree.  .  .  .  And  thus 
one  sees,  often  with  astonishment,  in  the  reports  of  the  necropsies, 
how  often  the  stenosis  and  destruction  of  the  cartilages  occur,  as 
it  were,  'without  even  any  symptoms.'  " 

Liining's  statistics  seem  to  show  that  severe  larvngeal  ulcer- 
ation  is  far  more  frequent  in  Germany  than  in  England  or 
America. 

Keen's  essay  points  out  that  cutaneous  emphysema  and  sup- 
puration of  the  mediastinum  may  follow^  perforative  ulceration  of 
the  larynx,  and  Wilks^  records  the  case  of  a  patient  of  twelve 
years,  who  on  the  twelfth  day  of  the  disease  developed  general 
cutaneous  emphysema  due   to   this   cause.      Denham"  records  a 

1  Wilks.     Medical  Times  and  Gazette,  1S62,  vol.  ii,  p.  276. 

*  Denham.     Holmes'  System  of  Siirgery,  2d  ed.,  vol.  iv,  p.  571. 


100  WELL-DEVELOPED  STAGE  OF  THE  DLSEASE 

similar  case  in  a  boy  of  the  same  age,  and  ChomeP  another  in  a 
man  of  twenty  years,  from  a  perforation  of  the  thyroid  cartihige. 
One  instance  is  rccordetl  hy  Liining  in  which  an  al^scess  had 
destroyed  the  arytenoids  and  rendered  the  cricoid  cartilage 
necrotic,  so  that  the  anterior  niediastinnm  was  filled  with  pus, 
and  lletslay"  records  still  another  in  which  a  perichondria!  abscess 
about  the  thyroid  cartilage  caused  secondary  involvement  of  the 
anterior  and  posterior  mediastinum. 

Keen's  table  shows  that  in  146  cases  of  severe  laryngeal  dis- 
ease 12  occurred  mider  fifteen  years,  87  between  fifteen  antl  twenty- 
five  years,  and  47  over  twenty-five  years. 

The  marked  exemption  of  children  from  laryngeal  involvement 
is  evidently  associated  with  the  mild  character  of  the  disease  in 
this  class  of  patients.  Liining's  table  of  165  cases  showed  18  under 
fifteen  years,  109  between  fifteen  and  twenty-five  years,  28  between 
twenty-five  and  thirty  years,  and  10  between  thirty  and  thirty-five 
years  or  over.  The  far  greater  frecjuency  of  the  malady  in  men 
than  in  women  is  interesting,  for  in  the  female  the  general  disease 
is  as  severe  as  in  males,  as  a  rule,  yet  in  Keen's  table  there  were 
119  males  to  29  females,  and  in  Liining's  table  129  males  to  36 
females.  Keen  tells  us,  in  regard  to  the  date  of  onset,  that  7  cases 
occurred  in  the  first  week,  23  in  the  second,  30  in  the  third,  and 
82  from  the  fourth  week  to  two  months  following  the  attack. 

Rieser  states  that  laryngeal  inflammation  may  occur  at  any  time 
between  the  first  and  the  tenth  week.  Over  70  per  cent,  of  the 
cases  reported  occurred  after  the  third  week. 

Keen  states  that  necrosis  of  the  cartilages  is  by  far  the  most 
common  and  also  by  far  the  most  dangerous  form  of  laryngeal 
affection,  but  adduces  no  evidence  in  support  of  its  being  the 
most  common  lesion.  Opposed  to  this  view  we  have  that  of  Lie- 
bermeister,  who  tells  us  that  "laryngeal  ulcers  do  not  in  any  way 
affect  the  ordinary  course  of  the  disease,  and  in  favorable  cases 
heal  without  leaving  any  evil  consequences."  "Occasionally," 
he  tells  us,  "they  may  lead  to  death  by  producing  perichondritis 
laryngea  or  glottic  oedema."     This  difference  of  opinion  rests  upon 

»  Chomel.     Thfise  de  Paris,  1877. 

^  Retslay.     Ueber  Perichondritis  Laryngea,  Berlin  Di.-sert.,  1870,  No.  10. 


THE  RESPfRATOh'Y  syST/<:M  IN  Tllh:  hlA' IJJil' i:i)  STACH     \{)\ 

a  (lid'ciciicc  ill  (he  sc\'ciily  of  tlic  l('.si(Hi.s.  Siir^con.s  only  iiwft 
witli  cases  which  are  sevcsre  eiuju^h  to  (leiriJiiifl  o[)('ra(ive  rcjUef, 
whereas  physicians  more  coininoiily  see  the  milder  lorms.  Wlicn 
necrosis  of  the  cartilage  does  take  place  there  can  be  no  douht 
that  Keen's  statement  as  to  the  danger  being  great  is  correct,  for 
in  this  condition  his  statistics  show  that  the  mortality  approximates 
95  per  cent.  In  197  cases  of  laryngeal  stenosis  in  enteric  fever 
Keen  records  a  mortalily  of  i)7  per  cent.,  whicli  if  the  cases  are 
divided  into  those  operated  on  by  tracheotomy  ef|uals  55.5  per 
cent.,  and  not  operated  on,  78.0  per  cent.  That  operation  is 
imperative  as  soon  as  suffocative  attacks  are  threatened,  is 
evident. 

If  laryngeal  stenosis  develop  and  the  symptoms  are  urgent,  an 
early  tracheotomy  under  a  local  anoesthetic  is  indicated,  and  Jackson 
asserts  that  this  operation  will  cure  almost  every  case.  Cases  of 
laryngeal  stenosis  due  to  infection  during  typhoid  fever  may  be 
saved  by  tracheotomy,  but  in  most  cases,  altliough  the  stenosis 
of  the  larynx  adds  to  the  discomfort  of  the  patient,  it  is  the  grave 
toxaemia  whicli  brings  about  the  fatal  result,  and  therefore  trache- 
otomy can  accomplish  little  as  far  as  ultimate  recovery  is  concerned. 

The  laryngeal  ulceration  which  occurs  in  a  fairly  large  proportion 
of  the  severe  cases  is  at  times  due  to  secondary  infiltration  of  the 
laryngeal  mucous  membrane,  apart  from  true  infection,  arising 
from  the  general  debility  of  the  patient.  Usually  these  ulcers 
form  at  the  posterior  part  of  the  larynx,  and  often  involve  the 
insertion  of  the  vocal  bands.  Under  these  circumstances  they 
may  cause  hoarseness  and  aphonia,  and  often  they  exist  if  in  mod- 
erate degree,  with  but  little  discomfort  to  the  patient.  Rarely  a 
painful  laryngeal  cough  develops,  and  if  they  extend  to  the  epi- 
glottis they  may  cause  pain  in  swallowing.  Rarely  they  produce 
perichondritis  of  the  larynx  or  oedema  of  the  glottis. 

In  reference  to  this  important  subject  we  are  glad  to  note  that 
Chevalier  Jackson,^  a  well-known  laryngologist  of  Pittsburg,  has 
drawn  particular  attention  to  the  importance  of  making  laryngo- 
logical  examinations  of  patients  severely  ill  of  typhoid  fever.  He 
bases  liis  deductions  upon  his  personal  study  of  360  such  cases,  and 

1  Jackson.     American  Journal  of  the  Medical  Sciences,  Xovember,  1905. 


102  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

finds  that  severe  and  even  fatal  lesions  of  the  larynx  are  by  no  means 
uncommon  thu'ing  the  course  of  typhoid  fever.  He  believes  that 
death,  due,  to  laryngeal  stenosis,  during  typhoid  fever,  without  the 
laryngeal  lesion  being  suspected  sometimes  occurs.  The  degree 
of  toxaemia  apparently  determines  the  severity  of  the  laryngeal 
lesion,  and  thrombosis  of  the  vessels  of  the  mucosa  is  the  first 
apparent  result  of  the  initial  inflammation.  Jackson  is  of  the 
opinion  that  laryngeal  lesions  due  to  the  Bacillus  typhosus  are 
exceedingly  rare,  and  looks  upon  the  majority  of  the  lesions  as  the 
result  of  infection  by  other  bacteria. 

The  prophylactic  measures  to  prevent  the  occurrence  of  this 
complication  are  necessary,  and  consist  chiefly  in  the  care  of  tlie 
mouth  and  teetli  from  the  beginning  of  the  illness.  The  more  ill 
the  patient  the  greater  the  necessity  of  care  regarding  the  condition 
of  mouth  and  teeth.  The  daily  use  of  a  tooth  brush  followed  by  a 
mouth  wash,  consisting  of  one  part  of  peroxide  of  hydrogen  and 
three  parts  of  water,  will  go  far  toward  keeping  the  oral  cavity  in 
a  sanitary  condition.  This  treatment,  with,  the  frequent  use  of 
more  pleasant  but  less  efficient  mouth  washes,  will  add  much  to  the 
comfort  of  the  patient;  and  if  a  laryngeal  lesion  does  develop,  the 
mouth  and  throat  vnW  be  less  like  a  culture  medium  for  germs. 

Bronchitis. — ^The  bronchitis  of  advanced  typhoid  fever  is  a 
very  constant  symptom,  so  constant  that  it  really  forms  part  of 
the  symptom-complex  of  the  regular  disease. 

Osler^  mentions  a  case  at  the  Johns  Hopkins  Hospital,  in  which 
"the  bronchitis  was  so  severe  and  the  cyanosis  so  extreme  that 
bleeding  to  the  extent  of  twelve  ounces  was  resorted  to."  The 
patient  died  a  few  hours  following  the  bleeding.  The  autopsy 
revealed  the  characteristic  intestinal  lesions  of  typhoid  fever  and 
both  lungs  showed  congestion  and  oedema,  without  any  foci  of 
inflammation.     The  bronchi  contained  a  quantity  of  frothy  serum. 

Osier's  remark  concerning  the  case,  to  the  effect  that  "this  is 
the  only  instance  in  which  a  patient  under  my  care,  with  typhoid 
fever,  was  bled,"  is  worth  remembering. 

Pneumonia. — It  is  only  when  bronchitis  becomes  severe  and 
passes  into  a  bronchopneumonia  that  it  possesses  any  considerable 

'  Osier.     Johns  Hopkins  Hospital  Bulletin  (Studies  in  Typhoid  Fever,  No.  2). 


THE  h'/'JSI'/h'A'/'Oh')-   S)'STh'M  IN  TIIH  l)i:\  i:iJ)l-i:i)  STACH     \{):', 

interest,  for  if  at  all  well  deveh^pcd  i(  hcconic;  ;i  otjivc  rii<ii;iff  (o 
the  patient's  life.  This  lobular  [)Mciiinoiii;i  (|(|)(ii(U  ii|(')ii  Coin-  cj*;!- 
rate  causes  for  its  existence.  First,  llic  hroiicliiiii  iiiii;i(ioii  cluu-io 
teristi(;  of  the  diseiise;  second,  the  feeldc  rcspiraioi y  niovcni(;nts  of 
the  patient,  and  tlu;  dorsal  decubitus  whereby  (Icpcndcnt  portions 
of  the  lung  collapse;  third,  the  feeble  circulal ion  wliicji  permits  stasis 
in  the  pulmonary  vessels;  and  finally,  and  vi^^y  imj^ortant,  the  in- 
spiration into  the  lungs  of  particles  of  food  or  foreign  bodies  in  the 
mouth  or  nose  which  are  septic,  or  which  decompose,  and  produce 
pneumonia  in  this  maimer.  The  physical  signs  of  this  form  of  the 
disease  are  identical  with  those  of  ordinary  lobular  j)n('mnonia,  and 
the  prognosis  is  bad  in  direct  proportion  to  the  feebleness  of  the 
heart  and  general  system,  the  extent  of  the  lesion,  and  the  slowness 
with  which  the  heart  and  general  system  respond  to  stimulation. 
Hoffmann  tells  us  that  this  complication  was  found  38  times  in  250 
autopsies;  so  it  is  evident  that  its  influence  in  producing  a  fatal 
result  is  probably  not  very  great,  as  a  rule.  It  is  emphatically  a 
symptom  pertaining  to  feeble  and  debilitated  patients,  and  most 
often  comes  on  in  the  latter  part  of  the  second  or  third  week.  As 
is  often  the  case,  lobular  pneumonia  may  afford  a  favorable  field 
for  the  growth  of  the  Bacillus  tuberculosis,  and,  therefore,  in  those 
cases  in  which  resolution  does  not  take  place,  pulmonary  phtliisis 
not  infrequently  follows  this  form  of  the  disease.  INIettenheimer^ 
saw  thirteen  cases  of  this  character  out  of  tliirty-eight  deaths  from 
typhoid  fever  or  its  sequela\ 

Fisher^  reports  four  fatal  cases  of  lobar  p7ieunionia  during  the 
course  of  typhoid  fever,  and  quotes  Liebermeister,^  who  states  that 
in  1420  cases  of  typhoid  fever,  lobar  pneumonia  occurred  52  times 
with  29  deaths.  INIarignac''  also  reported  13  instances  of  lobar 
pneumonia  complicating  typhoid  fever  with  but  tlii'ee  recoveries. 

Canby  Robinson,^  of  the  Pennsylvania  Hospital,  has  called 
attention  to  the  role  of  the  typhoid  bacillus  in  the  pulmonary 
comphcations  of  this  disease.     His  experience  with  three  patients 

1  Mettenheitner.  Beobachtungen  iiber  die  typhoiden  Erkrankungen  der  franzosischen 
Konigsgefangenen  in  Schwerin,  Berlin,  1879. 

-  Fisher.     American  Journal  of  the  Medical  Sciences,  August,  1901. 

^  Liebermeister.     Ziemssen's  Cyclopedia.  *  Marignac.     Paris  Theses,  1S77 

^  Robinson.     Journal  of  Infectious  Disease,  1905,  pp.  498-510. 


104  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

suffering  with  typhoid  fever  compHcated  by  pncuinonia  lead  him 
to  conclude  that: 

"  The  typhoid  bacilhis  not  infrequently  invades  the  lung  during 
typhoid  fe\'er. 

"  It  may  invade  areas  of  the  lung  already  the  seat  of  hem- 
orrhagic infarction  and  there  produce  abscess  formation  and 
gangrene. 

"  The  organism  may  cause  bronchopneumonia. 

"Lobar  pneumonia,  as  a  complication  of  typhoid  fever,  is 
usually  due  to  the  pneumococcus.  This  organism  may  be  present 
as  a  general  infection  in  the  circulating  blood  simultaneously  with 
the  B.  typhosus.  It  is  probable  that  both  B.  typhosus  and  B. 
paratyphosus  can  produce  a  massive  pneumonia,  lobar  in  type. 
When  these  organisms  are  the  causative  factors  the  pneumonia 
is  of  a  peculiar  hemorrhagic  character,  which  may  be  recognized 
clinically  by  the  bloody  nature  of  the  sputum. 

"  The  typhoid  bacillus  is  not  infrequently  found  in  the  sputum 
of  typhoid  fever  patients  with  pulmonary  complications.  This 
fact  should  be  emphasized  in  order  that  spread  of  the  disease  by 
this  means  may  be  prevented," 

Very  much  more  rarely  acute  miliary  tuberculosis  develops  in 
typhoid  fever,  probably  because  the  focus  of  some  earlier  and 
dormant  tuberculous  infection  breaks  down  and  sets  free  tubercle 
bacilli  in  a  system  the  vitality  of  which  is  depressed.  Hoffmann 
found  it  four  times  in  250  typhoid  fever  autopsies. 

It  is  to  be  remembered  that  it  is  far  more  common  to  mistake 
an  acute  tuberculosis  for  typhoid  fever  than  to  have  tuberculosis 
ensue  as  a  complication  of  typhoid  fever.  It  is  often  noted  in  the 
histories  of  tuberculous  patients  that  they  have  had  several  illnesses 
which  were  thought  to  be  typhoid  fever,  when  in  reality  each  illness 
was  probably  due  to  a  fresh  tuberculous  outbreak. 

Hypostatic  congestion  of  the  lungs,  a  condition  closely  allied  in 
causation  and  prognosis  to  lobular  pneumonia,  occurred  in  100 
out  of  1420  cases  recorded  by  Liebermeister,  and  pulmonary 
oedema  is  the  usual  immediate  cause  of  death  in  cases  which  die 
of  failure  of  the  cardiac  muscle,  as  Hoffmann  has  proved. 

Cases  of  pneumonia  occurring  during  typhoid  fever  may  be 


TIIM  RESPIRArO/iV  SVST/'JM  /A'  77/A'  bl-A' HLOI'i:!)  ^TAdl-:     !().> 

divided  iiilo  (lio.sc  occiirriiifi;  iil  (he  ousel,  of  llic  illness  ;iiid  tlio^cr 
OCCUrriii<i,'  diirin;^'  ilie  course  of  ihe  fever.  When  llie  pnenuioniii 
usliers  in  the  attaek  of  typhoid  lexer  (see  page  51,  "I'rieunifi- 
typlioid")  the  symptoms  of  pneumonitis  so  mask  those  produced 
by  the  Bacillus  typhosus  that  a  diagnosis  of  pneumonia  is  often 
made  and  maintained  for  days  luilii  some  characteristic  sign  of 
typhoid  fever,  such  as  hemorrhage  fi'om  the  bowel  or  tlie  ap[;ear- 
ance  of  the  specific  eruption,  reveals  the  true  nature  of  the  illness. 
Sometimes  the  diagnosis  is  not  made  except  at  the  autopsy.  Osier 
has  reported  a  case  that  was  admitted  to  his  wards  with  all  the 
usual  symptoms  and  signs  of  pneumonia  and  during  the  forty- 
eight  hours  that  preceded  death  there  was  nothing  observed  which 
cast  doubt  upon  the  diagnosis  of  this  disease,  but  autopsy  revealed 
a  well-developed  case  of  typhoid  fever.  In  still  another  case  In 
Osier's  wards  the  symptoms  were  mosdy  pulmonary,  and  for 
eleven  days  the  presence  of  typhoid  fever  was  not  suspected.  The 
occurrence  of  pneumonia  during  the  course  of  typhoid  fever  is  a 
very  serious  complication  and  its  presence  is  often  the  factor  which 
serves  to  turn  the  scales  against  the  patient.  In  Osier's  series 
of  829  cases  of  typhoid  fever  there  were  fifteen  examples  of  lobar 
pneumonia. 

True  croupous  pneumonia  occmTing  in  the  later  stages  of  typhoid 
fever,  either  as  a  result  of  an  infection  with  the  Streptococcus  lan- 
ceolatus  or  by  the  bacillus  of  Eberth,  is  a  very  rare  affection,  much 
more  rare  than  it  is  in  the  stage  of  onset  as  already  pointed  out. 
Hoffmann  found  it  present  only  eighteen  times  in  250  typhoid 
autopsies.  x\gain,  in  1420  cases  quoted  by  Liebermeister,  52  cases 
had  "extensive  consolidation"  of  the  limg  not  dependent  on 
hypostatic  congestion,  A  "good  many"  of  these,  however,  were 
probably  cases  of  true  lobular  pneumonia  and  were  not  croupous. 

In  tliis  connection  it  is  interesting  to  note  that  as  long  ago  as 
1839  Becquerel  ^^Tote  an  article  on  pneumonia  complicating 
typhoid  fever  when  making  an  analysis  of  eighteen  cases  in  the 
service  of  Jadelot  in  1837. 

Hemorrhagic  infarction  of  the  lungs  arises  in  t\*phoid  fever 
from  several  causes,  and  is  usually  met  with  in  cases  with  greatly 
impaired  circulation.     It  is  due  to  emboli  arising  in  the  right  side 


106  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

of  the  heart,  or,  very  rarely,  to  emboli  arisino-  from  a  plilel)iti.s. 
(See  drculation  in  convalescence.) 

It  has  been  .sugij;esteil  (hat  it  may  arise,  when  septic,  from  the 
intestinal  ulcers,  but  no  case  of  this  l-ind  has  come  to  onr  notice. 

Sometimes  it  may  arise  from  a  bed-sore,  a  parotid  abscess,  or 
from  an  abscess  elsewhere. 

In  many  cases  the  presence  of  small  infarctions  is  unsuspected, 
either  because  they  cause  little  difficulty  or  because  they  are  not 
differentiated  from  lobular  pneumonia,  the  physical  signs  in  each 
case  being  nearly  identical.  When  the  infarction  is  large  we  have 
a  rise  of  temperature,  pain  in  the  chest,  currant-jelly  blood  in  the 
sputum,  and,  if  the  embolus  is  septic  and  the  patient  survives,  signs 
of  pulmonary  abscess  or  gangrene.  Sometimes  the  infarction  is 
due  to  thrombosis.  The  presence  of  a  focus  which  can  supply  an 
embolus  increases  the  probability  of  the  pulmonary  difficulty  being 
infarction,  and  an  infarction  severe  enough  to  be  recognized  is  of 
evil  prognostic  omen.  Out  of  250  typhoid  autopsies,  Hoffmann 
found  fifteen  cases  of  hemorrhagic  pulmonary  infarction. 

That  haemoptysis  may  complicate  typhoid  fever  in  a  patient 
free  from  tuberculosis  is  questionable  unless  there  also  be  present 
hemorrhagic  infarction  or  pneumonia.  Creagh^  has  reported  an 
instance  in  a  man  of  thirty-five  years;  the  accident  resulting  in 
death.  Unfortunately,  no  autopsy  was  made  in  this  case  to  prove 
that  there  was  no  local  tuberculous  lesion. 

Pleuritis. — Primary  pleurisy  complicating  typhoid  fever  is  very 
rare.  Nearly  always  it  is  secondary  to  infarction,  pneumonia,  or 
gangrene.  Rarely  it  may  be  due  to  direct  typhoid  infection,  and 
when  this  is  the  case  the  effusion  is  usually  purulent.  As  early  as 
1885  Rendu  and  de  Gennes,"  and  in  1887  A.  FraenkeP  obtained 
the  bacillus  of  Eberth  from  the  pus  of  an  empyema.  In  Keen's 
essay  Westcott  collected  nine  instances  of  typhoid  pleural  effusion, 
in  five  of  which  this  specific  organism  was  found.  As  a  rule,  this 
state  comes  on  as  a  late  symptom,  not  earlier  than  the  third  week, 
or  sometimes  not  until  two  months  after  the  fever. 


1  Creagh.     London  Lancet,  November  30,  1895. 

2  Rendu  and  de  Gennes.     La  France  Mdd.,  1885,  vol.  ii,  p.  1821. 

3  Fraenkel.     Verhandlungen  Sechste  Kongress  fiir  inner.  Med.,  1887,  p.  179. 


■THE  RKSi'JUA'J'oin'  hyhti<:m  in  Till':  hi'A  i:l()I'I':i)  i^taci-:    107 

Further,  in  ,siij)|K)rt  of  tlu;  sliiUnncMl,  jis  I,o  (Ik;  .s(;f:oi)(J;iry  cluir- 
acter  of  pleurisy,  out  of  these. nine  ciiscs  it  siifrccrlcfl  jhicuhio- 
thorax  once/  pulmonary  abscess  once,'' ^^anf^icnc  of  ihc  Inn;:  onr-e,' 
and  suppurative  inediastinitis  once."* 

Nordman  and  liillet"'  draw  iitlcnfion  (o  the  f;if(  (hut  pleural 
effusions  occurring  after  the  tliiid  \\(('!<  of  typhoid  fever  often 
contain  Eberdi's  bacillus  ;iiid  (he  (hiid  n;iv(s  the  agglutinating 
reactioji.  Archard"  conHrms  this  sta(einent,  and  reports  several 
instances  in  which  this  organism  was  found.  MichaeP  believes  that 
in  certain  rare  instances  there  is  an  actual  infection  of  the  pleura  by 
typhoid  bacillus.  Sears^  has  discussed  the  pleurisies  com}jlicating 
typhoid  fever  and  added  eighteen  cases  to  the  number  collected 
by  llemlinger,"  which  makes  57,  of  which  48  occurred  in  males 
and  0  in  females.  Sears  found  that  this  complication  occurred 
either  in  the  very  early  stage  of  the  disease  or  during  convalescence. 
Its  onset  was  usually  insidious  and  only  discovered  by  physical 
examination.  Of  the  effusions  aspirated,  16  were  serous,  17  were 
purulent,  and  7  hemorrhagic.  In  Osier's  series  of  829  cases  there 
occurred  but  one  instance  of  empyema,  from  the  pus  of  which  the 
Bacillus  typhosus  was  isolated. 

A  case  of  empyema  complicating  relapse  in  typhoid  fever,  in 
the  pus  of  which  typhoid  bacilli  were  found  in  large  numbers,  has 
been  recorded  by  Valentine.  ^° 

The  prognosis  is  apparently  very  good,  as  six  of  Keen's  nine 
cases  recovered  after  aspii'ation  or  drainage,  including  one  case 
with  pus  in  the  mediastinum. 

Empyema  due  to  the  streptococcus,  occurring  in  the  course  of 
typhoid  fever,  is  also  reported  by  Hanquet." 

Gangrene. — ^A  case  of  gangrene  of  the  lung  in  a  bov  of  eight 

DO  O  .0 

1  Rendu.  La  France  Medicale,  1885,  vol.  ii,  p.  1S09. 
^  Ramsey.  Annals  of  Surgery,  January,  1890,  p.  39. 
^  Griesinger.     Infectionskrankheiten. 

*  Barr.     Liverpool  Medico-Chirurgical  Journal,  1893,  vol.  xiii,  p.  346. 
'  Nordman  and  Billet.     Archives  Generale  de  M<?decine,  1906. 

"  Archard.  La  Semaine  Medicale,  October  19,  1S9S. 
'  Michael.     Gazette  des  Hopitaux,  1901. 

*  Sears.     Boston  Medical  and  Surgical  Magazine,  December  4,  1902. 
'  Remlinger.     Revue  de  M^decine,  1900,  No.  12. 

'"  Valentine.     Berliner  klin.  Wochenschrift,  1SS9,  No.  15. 
^1  Hanquet.     Archives  Medicale  Beiges,  Jime,  1892. 


lOS  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

years,  occurring  as  a  sequel  to  typhoid  fever,  has  been  recorded 
bv  Acker/     Death  occurred. 

Robinson-  has  reported  a  case  of  gangrene  of  the  lung  from  the 
wards  of  thie  Pennsylvania  Hospital.  In  this  case  the  specific 
organism  of  typhoid  fever  was  found  in  the  local  lung  lesion. 

rNEUiMOTnoRAX  during  typhoid  fever  is  a  rare  complication,, 
and  must  usually  be  looked  upon  as  an  accidental  occurrence. 
Hale  White  has  reported  two  cases  which  suffered  from  this 
condition  during  typhoid  fever.  Both  patients  had  pleurisy,  but 
at  autopsv  no  gross  lesion  was  found  in  either  the  lungs  or  bronchi. 

Circulation  in  the  Developed  Stag'e  of  the  Disease. — The 
development  of  the  fever  in  this  disease  is  accompanied  by  an- 
acceleration  of  the  pulse-rate,  as  it  is  in  all  maladies.  With  the 
onset  of  the  malady  the  heart,  not  yet  weakened  by  illness,  may 
not  only  greatly  quicken  its  beat,  but  also  cause  the  pulse  to  be 
much  stronger  than  normal.  As  the  disease  progresses,  however, 
the  pulse  becomes  weaker  and  weaker  in  severe  cases,  and  the  heart 
sounds  more  and  more  feeble  until  they  may  be  inaudible  even  with 
the  most  careful  auscultation.  With  the  ordinary  quickening  of 
the  pulse  and  its  common  alterations  we  have  little  to  do  at  this- 
point.  The  states  that  interest  us  are  the  unusual  variations, 
wliich  consist  chiefly  in  dicrotism,  tachycardia,  bradycardia,  and 
intermittence,  relaxation  of  the  vascular  pathways  on  the  one 
hand,  and  aberrant  action  of  the  heart  as  to  force  and  sounds  on 
the  other.  Dicrotism  may  be  present  for  days  at  a  time  in  feeble 
cases,  and  is  an  unfavorable  sign  of  not  great  gravity  unless  asso- 
ciated with  other  grave  symptoms.  Ordinarily  pulse-rates  var^ang 
between  80  to  120  can  be  regarded  by  the  physician  with  equa- 
nimity, although  much  depends  upon  the  character  of  the  pulse, 
and  still  more  upon  the  quality  of  the  heart  sounds,  which  should 
always  be  studied  in  connection  Avdth  the  pulse.  W^ith  each  ten 
additional  beats  the  gravity  of  the  condition  greatly  increases, 
and  if  a  pulse  rises  to  140  or  150  per  minute  without  some  momen- 
tary exciting  cause,  and  remains  so  rapid,  the  condition  is  indica- 
tive of  great  danger.     If  at  the  same  time  there  is  coldness  of 

1  Acker.     Archives  of  Pediatrics,  September,  1896. 

2  Robinson.     Journal  of  Infectious  Disease,  1905,  p.  498  to  510. 


€IRCULA  TION  IN  TJf/'J  Dh:  Vh'fJ)J'/'J/J  ST  A  CE  OF  Till-:  1)1  Si:  A  Si:     \  {)[) 

the  extremities,  iii(lc|)(ii(lciil  o^i  cont;!*!  wiih  jcoha^f.s  ov  oilier 
extraneous  causo^s,  dissoliilioii  iii;iy  Im-  ininiinciit.  Miie-h  depends, 
however,  ii])()ii  tlic  (|ii.'dity  u\  \\\c  pulse-wave.  11"  i(  is  full  and 
possesses  iiii  approxiinately  iionnal  tension,  the  danger  is  less  ^rave 
than  if  it  is  gaseous  and  relaxed  and  easily  (extinguished.  Some- 
times auscultation  of  the  heart  will  show  I  hat  it  is  acting  strongly 
yet  pumping  futilely  in  an  attempt  to  fill  relaxed  and  dilated  vessels. 

It  has  been  asserted  by  some  clinicians  that  much  prognostic 
information  can  be  gained  from  the  heart  sounds  in  typhoid  fever. 
Thus,  Landouzy,  Picot,  Iluchard,  and  others  have  formulated  this 
conclusion,  namely,  that  the  disappearance  of  the  first  sound  of 
the  heart  at  the  apex  or  at  the  base  in  the  course  of  typhoid  fever 
constitutes  an  evil  sign  if  the  pulse-rate  goes  as  high  as  110,  and 
that  if  the  sound  be  absent  and  the  pulse-rate  increases  in  excess 
of  this  number  per  minute,  the  prognosis  is  fatal.  Of  course,  any 
condition  of  profound  depression  in  the  heart  or  in  general  strength 
which  can  extinguish  the  first  sound  is  more  or  less  grave,  but 
the  association  of  this  disappearance  with  high  pulse-rate  they 
consider  a  very  evil  omen.  Mongour^  has  recently  written  a  paper 
on  this  theme  confirmatory  of  these  views. 

In  still  other  instances  the  heart  sounds  are  like  those  of  a 
foetus,  the  long  pause  being  absent.  This  "  embryocardia " 
indicates  grave  cardiac  feebleness. 

As  already  stated,  these  circulatory  changes  have  been  cliiefly 
discussed  by  French  clinicians.  Bernheim'  has  described  a  variety 
of  typhoid  fever  that  he  calls  "forme  cardiaque,"  the  chief  signs 
of  wliich  are  a  condition  of  asystole  and  cardiac  feebleness. 
Demange^  has  also  written  on  this  topic,  and  Potain  is  quoted 
by  Homolle  in  his  article  on  typhoid  fever,  in  Jaccoud's  Diction- 
naire,  as  having  found  a  constant  decrease  of  arterial  pressiu-e  by 
means  of  the  sphygmomanometer  of  Basch.  This  reduction  of 
pressure  is  an  almost  constant  symptom,  as  everyone  knows  who 
has  studied  the  pulse  of  patients  suffering  T\-ith  this  disease. 

In  other  cases,  which  are  rare,  comparatively  speaking,  the 
pulse-rate  remains  at  or  below  the  normal  all  tlirough  the  attack. 

1  Mongour.     La  Presse  Medicale,  April  21,  1S97. 

-  Bernheim.     Association  pour  TAvancenient  des  Sciences;  Congres  de  la  Rochelle,  1SS2. 

5  Demange.     Revue  de  Mi^decine,  1SS5,  p.  1025. 


no  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

This  is  without  any  particular  import,  ami  was  thought  by  the 
older  wTiters,  such  as  Huf eland,  Sauvages,  and  Berndt,  to  be 
quite  pathognomonic  of  this  disease.  Liebermeister  states  that  a 
goo.l  pulse  in  typhoid  fever  rarely  rises  above  110. 

If  the  circulation  distinctly  fails,  congestion  of  the  veins  may 
develop,  but  the  surface  of  the  body  instead  of  becoming  cyanotic 
or  congested  in  appearance,  often  becomes  pallid  and  relaxed,  a 
profuse  sweat  often  being  present,  even  though  the  temperature 
may  be  as  high  as  104°. 

Over  and  above  these  gradual  signs  of  circulatory  failure,  sud- 
den collapse  from  hemorrhage  or  perforation  may  develop.  (See 
article  on  alimentary  canal.)  A  sudden  diarrhoea  or  an  attack 
of  vomiting  may,  however,  cause  a  syncopal  attack,  and  a  sud- 
den fall  of  high  temperature  due  to  some  complicating  state 
may  also  do  so.  Liebermeister,  though  an  ardent  advocate  of  the 
cold  bath,  says:  "Sometimes  a  condition  resembling  collapse  is 
seen  to  follow  a  cold  bath."  So  far  as  prognosis  is  concerned, 
care  should  be  taken  to  separate  the  collapse  of  defervescence 
from  that  due  to  grave  cardiac  degeneration.  (For  circulatory 
accidents,  see  chapter  on  the  circulatory  system  in  the  stage  of 
convalescence.) 

In  connection  with  this  subject,  attention  should  be  called  to 
the  profound  exhaustion  and  depression,  chiefly  manifested  at  the 
close  of  severe  typhoid  fever,  which  has  a  tendency  to  cause 
death  from  asthenia.  This  state  was  far  more  frequently  met  with 
some  years  ago,  when  the  infection  seemed  more  virulent  than  it 
does  today,  and  when  the  treatment  was  not  so  well  understood. 
This  condition  of  the  patient  has  been  described  by  Iluxham  in 
his  Essay  on  Fevers,  1750,  p.  78,  in  the  following  words: 

"Now  Nature  sinks  apace,  the  extremities  grow  cold,  the  nails 
pale  and  livid,  the  pulse  may  be  said  to  tremble  and  flutter  rather 
than  to  beat,  the  vibrations  being  so  exceedingly  weak  and  quick 
that  they  can  scarce  be  distinguished,  though  sometimes  they  creep 
on  surprisingly  slow,  and  very  frequently  intermit.  The  sick  be- 
come quite  insensible  and  stupid,  scarce  affected  with  the  loudest 
noise  or  the  strongest  light,  though  at  the  beginning  strangely 
susceptive  of  the  impressions  of  either.     The  delirium  now  ends 


emeu  LA  T/ON  IN  riii<:  J)EVfj/)I'I':i)  sta  (ii-:  of  tii  /•;  hi  si:  a  si-:   \  \  \ 

in  a  proiOiiiid  coiiui,  ;iii<l  IIimI  soon  in  ((cin;!!  .slcc[>.  'I  In-  stools, 
urine,  and  tears  r(ui  oil"  involiinliirily,  and  iinnonriff;  a  s|K;(;dy  dis- 
solution, as  the  vast  treinl)lint(s  ;ind  twit(;hinn;s  of  llie  iktvcs  ;ind 
tendons  are  preludes  to  a  ^cnci;!!  eonvulsioii,  wliifli  :it  onff  n.ips 
off  the  thread  of  Hfe.  In  one  or  oilier  of  tliese  ways  are  the  sick 
carried  off,  after  haviii*;"  lannuislicd  on  for  fourfeen,  ei^ditofTi,  or 
twenty  days,  nay,  sometimes  for  miicli  longer." 

EndocAEDITIS. — The  bacillus  of  Ebertli  lias  been  is(jlated  from 
the  endocardium  of  a  patient  dying  of  this  disease  in  but  few 
instances  (by  (jlirode  and  Vincent),  but  the  usual  cause  of  the 
complication  is  a  mixed  infection.  In  Osier's  first  case,  which 
he  saw  in  the  Philadelphia  Hospital  in  1886,  the  infection  was 
unusually  intense,  so  much  so  that  the  cjuestion  was  raised  as  to  the 
possibility  of  the  presence  of  malignant  endocarditis.  Griesingcr, 
Liebermeister,  and  Bochut  (all  quoted  by  Curschmami  in  Xoth- 
nagel's  Encyclopcodia  of  Practical  Medicine)  have  reported  cases  of 
ulcerative  endocarditis  occurring  during  the  course  of  typhoid 
fever,  and  such  reports  of  cardiac  complications  are  becoming  more 
frequent  in  current  literature,  which  fact  reveals  not  so  much  the 
increase  in  the  occurrence  of  such  complications,  but  that  more 
careful  physical  examinations  are  being  made. 

Acute  endocarditis  complicating  typhoid  fever  has  been  reported 
by  Carbone,^  The  patient  was  a  young  woman  who  had  the  classical 
symptoms  and  lesions  of  typhoid  fever,  and  from  whose  endo- 
cardium typhoid  bacilli  were  obtained.  These  bacilli  w^ere  injected 
intravenously  in  various  animals,  producing  the  same  lesion. 

ConnelP  has  also  recorded  a  case  of  infectious  endocarditis  in 
typhoid  fever,  due  to  the  staphylococcus  and  involving  the  mitral 
and  tricuspid  valves. 

Osier  met  with  but  tliree  cases  of  acute  endocarditis  in  his 
1500  cases  of  typhoid  fever,  while  von  Jaksch  observed  15  cases,  in 
a  German  clinic,  in  a  series  of  793  patients. 

Thayer^  found  in  his  exhaustive  study  of  the  cardiac  complica- 
tions of  typhoid  fever  that  12  of  the  188  cases  which  were  kept 
under  observation  for  three  months  to  fourteen  years  after  their 

1  Carbone.     Gazette  Medica  di  Torino,  1892,  No.  23. 

-  Connell.     Montreal  Medical  Journal,  August,  1S96. 

'  Thayer.     American  Journal  of  the  Medical  Sciences,  1904,  cxxvii,  pp.  391-422. 


112 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE 


attack  of  typhoid  fever,  had  signs  which  led  him  to  beUeve  that 
an  organic  cardiac  lesion  was  caused  by  the  primary  iUness. 

The  Blood  in  the  Developed  Stage  of  Typhoid  Fever. — In 
typhoid  fever  in  the  first  two  weeks  of  the  disease  we  usually  find 
little  if  any  change  in  the  red  corpuscles,  unless  an  active  diarrha^a 
be  present,  in  Avhich  case  there  may  be  concentration  of  the  blood 
cells.  In  the  tliu'd  week  the  red  cells  begin  to  decrease,  and  may 
get  as  low  as  in  cases  of  pernicious  anaMiiia.  The  lowest  point  is 
reached  about  the  end  of  the  fii'st  week  of  convalescence,  when 
they  gradually  begin  to  increase.  The  hannoglobin  follows  the 
red  cells,  as  might  be  expected,  and  the  degree  of  the  ana^nia  is  in 
direct  proportion  to  the  severity  of  the  infection  in  most  instances. 

Emerson^  has  recorded  two  cases  of  typhoid  fever  with  interest- 
ing blood  crises  in  which  cases  the  erythrocytes  were  apparently 
disintegrated  by  the  toxin  of  the  Bacillus  typhosus. 

The  most  noteworthy  fact  about  the  blood  in  this  fever  is  that,  as 
a  rule,  there  is  no  constant  increase  in  the  leukocytes  unless  some 
intercurrent  inflammation  is  set  up.  Cabot  asserts,  however,  that 
sometimes  leukocytosis  does  occm*  without  any  complication  that 
can  be  found.  On  the  other  hand,  in  patients  profoundly  asthenic 
from  this  disease  complications  may  not  cause  leukocytosis.  As  an 
illustration  of  the  manner  in  which  these  accidents  may  produce 
blood  chano-es,  the  following;  table  of  Cabot  is  of  interest: 

Leukocytes. 

Perforation.      Case  I         (a).  Five  days  before  operation        ....  8,300 

(6).  At  time  of  perforation 24,000 

Case  II               At  time  of  perforation 18,500 

Phlebitis.           Case  I         (o).  Two  days  before  onset 6,400 

(6).  At  time  of  onset 12,900 

(c).  One  week  later 10,100 

Case  II       (a).  One  week  before  onset 4,800 

(6).  At  time  of  onset 16,200 

Otitis  media.     Case  I         (a).  At  entrance           5,300 

(6).  Mastoid  abscess 16,400 

Case  II       (a).  At  entrance 8,400 

(6).  Two  weeks  later,  after  opening  drum  mem- 
brane (seropurulent  discharge)    .      .      .  11,200 

Case  III     (a).  At  entrance 7,320 

(fc).  Otitis 14,000 

Cabot  states  that  a  freely  discharging  otitis  soon  ceased  to  cause 
leukocytosis — e.  g.,  a  case  of  serous  otitis  media  seven  days  after 

I  Emerson.     Bulletin  of  the  Johns  Hopkins  Hospital,  October,  1907. 


Till']  BLOOD  IN  TIII'J  Di:  V  ICLOI'HI)  ST  A  OIJ  OF  T ) '  I'llni  h  /'/',  Vi:i!     |  |  ?, 

puncture,  but  still  (li,scliiic<i;iii^-  I'l-ccly,  shoucd  l)ii(  .").'i20  \\lii(c  cflls 
per  cubic  millirneter. 

An  abscess  of  the  buttock  raised  llic  count  from  S(JOO  to  J  I,2(j0, 
and  a  hemorrhage  from  8000  to  ]],.'^(J(). 

As  with  all  inflammations,  it  is  tlic  inrrciisc  in  flic  f;olyrnoi|>lio- 
nuclear  cells  which  is  characteristic. 

The  value  of  discovering  alterations  in  I  lie  blood  in  tyj;lioiri 
fever  is  very  great  for  diagnostic  purposes.  Increased  leukocyto.sis 
gives  us  reason  to  believe  that  there  is  present,  and  makes  us 
search  for,  some  complicatijig  inflammatory  focus,  such  as  pneu- 
monia, perforation,  cholecystitis,  phlebitis,  or  abscess  in  any  part 
of  the  body,  as  in  the  liver.  Further,  it  may  render  a  case  of 
suspected  typhoid  fever  clearly  one  of  appendicitis  or  some  other 
acute  inflammatory  affection. 

The  study  of  leukocytosis  is  useless  to  us  in  separating  malarial 
fever  from  typhoid  fever,  for  in  neither  affection  does  it  occur,  and 
the  same  statement  holds  true  as  to  tuberculosis  unless  the  latter  is 
accompanied  by  coincident  infections  with  pus  organisms,  when 
leukocytosis  may  be  present.^ 

The  blood  in  typhoid  fever  should  not  be  examined  after  a  bath, 
as  tliis  may  cause  a  temporary  leukocytosis  in  the  peripheral 
vessels. 

Bacteremia. — In  the  first  edition  of  this  essay  the  senior  author 
was  able  to  report  but  one  case  in  wliich  a  positive  blood  culture 
had  been  found.  Tliis  report  was  by  De  Grandmaison  and  Cartier," 
who  reported  the  case  of  a  woman  admitted  to  the  hospital  suflfering 
from  the  results  of  an  abortion.  She  presented  typical  symptoms 
of  typhoid  fever.  Her  blood  gave  a  positive  Widal  reaction,  and 
from  it  they  obtained  a  pure  culture  of  the  bacillus  of  Eberth. 
During  the  ten  years  that  have  passed  since  this  case  was  published, 
and  particularly  since  the  studies  of  Schottmiiller,  who,  in  1902, 
was  the  first  to  prove  that  in  typhoid  fever  we  are  dealing  -^-ith  a 
bacteremia,  there  have  occurred  so  many  cases  in  which  the  bacil- 
lus of  Eberth  has  been  recovered  from  the  blood  that  to  give  the 

1  Valuable  studies  of  these  questions  are  those  of  Cabot,  from  whose  book  on  the  blood 
we  have  quoted,  and  those  of  Thayer,  Johns  Hopkins  Hospital  Reports,  vol.  iv,  p.  S3.  Also 
Ouskow  and  Aporti  and  Radaeli,  Eleventh  Congress  for  Medical  Science,  Rome,  March,  1S94. 

"  De  Grandmaison  and  Cartier.     La  Presse  M^dicale,  February  1,  1899. 

8 


114  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

references  to  this  work  alone  wonkl  re(|uire  a  great  deal  of  space. 
It  is  sufficient  to  state  that  all  observers  who  have  studied  typhoitl 
fever  by  cultural  methods  agree  that  over  80  per  cent,  of  the  cases 
reveal  the  bacillus  in  the  blooil.  It  has  lieen  the  experience  of  all 
laboratory  workers  in  this  particular  fiekl,  that  by  blood  culture 
the  bacillus  can  often  be  found  before  the  fifth  day  of  the  disease. 

To  those  particularly  interested  in  the  subject  of  blood  cultures 
in  typhoid  fever  we  refer  to  re\'iews  by  Conradi/  Castellani," 
Kayser,^  IMuller  and  Graff/  Fornet,^  Schottmiiller,"  Coleman  and 
Buxton/  Cole/  and  Peabody.® 

The  Spleen. — The  changes  produced  in  the  spleen  are  usually 
developed  early  in  the  disease.  In  no  other  disease  condition, 
except  malaria  and  the  septic  fevers,  is  this  organ  so  constantly 
enlarged  as  in  typhoid  fever.  In  addition  to  the  frequency  of 
enlargement  of  the  spleen,  its  early  occurrence,  its  relatively  long 
duration,  and  its  constant  reappearance  in  relapses  make  splenic 
enlargement  especially  indicative,  when  combined  with  suspicious 
symptoms,  of  typhoid  fever. 

The  frequency  of  enlargement  of  the  spleen  during  typhoid 
fever  cannot  be  estimated  with  accuracy  by  physical  examination, 
although  in  the  great  majority  of  cases  the  spleen  is  palpable  after 
the  first  week  of  illness  and  continues  so  until  convalescence. 
Curschmann^'^  states  that  in  300  successive  autopsies  upon  typhoid 
fever  subjects  there  were  large  splenic  tumors  in  127,  tumors  of 
moderate  or  considerable  size  in  173.  In  no  case  was  enlarge- 
ment of  the  spleen  wanting.  Curschmann  also  states  that  in  577 
autopsies  upon  typhoid  fever  subjects  at  Hamburg  there  was 
absence  of  splenic  enlargement  noted  in  49. 

A  general  idea  of  the  statistics  of  splenic  enlargement  is  obtained 
by  comparing  the  estimates  made  at  Hamburg  and  Leipzig.     In 

1  Conradi.     Deutsch.  med.  Wocli.,  1907,  p.  1684. 

2  Castellani.     Centralbl.  f.  Allg.  Path.  u.  pathol.  Anat.,  1900,  vol.  ii,  p.  456. 

3  Kayser.     Munch,  med.  Woch.,  1906,  pp.  823  and  1953. 

<  Muller  and  Graff.     Centralbl.  f.  Bakt.,  1907,  No.  43,  p.  856. 

'  Fornet.     Miinch.  med.  Woch.,  1906,  p.  1053. 

«  Sehottmuller.     Deut.  med.  Woch.,  1900,  vol.  xxvi,  p.  511. 

7  Coleman  and  Buxton.     American  Journal  of  tlie  Medical  Sciences,  June,  1907. 

8  Cole.     Johns  Hopkins  Hospital  Bulletin,  1901,  vol.  xii,  p.  203. 

'  Peabody.     Journal  of  the  American  Medical  Association,  September  19,  1908. 
!■>  Curschmann.     Nothnagel's  Encyclopa;dia. 


GENITO-UUINARV  TRACT  IN  TIIH  l>i:V i:LOI'I:I)  STAC'/:      |  i."; 

2205  Ciiscs  in  i,]\('.  I  l!uiil)iii'<^'  I  I().s|)iliil,  s[)lciiif:  (iimor  Wiis  rlciiifHi- 
strated  in  LSfjO,  or  Sl.^)  per  cciiL;  \v;is  |);il|);il»|c  in  '.')].2  \>rv  ccitt.; 
and  uncertain  or  wanlin<i,'  in  )>lf5,  or  15.7  per  cent.  Jii  Leipzig, 
among  1626  cases,  splenic  tumor  was  demonstrable  in  1051,  or 
69.4  per  cent.;  was  uncertain  or  not  demonstrable  in  575,  or  30.0 
per  cent.  These  data  were  obtained  from  statistics  covering  a 
period  of  thirteen  years,  and  were  made  by  a  number  of  different 
observers. 

Under  the  name  splenotyphoid,  lOiselt'  has  described  a  condi- 
tion in  which,  according  to  his  description,  the  spleen  bears  the 
brunt  of  the  affection  and  the  intestinal  complications  are  absent. 
The  spleen  may  be  very  much  enlarged,  and  there  may  be  a  peri- 
splenitis with  adhesions.  In  another  form  the  spleen  becomes 
enormous  in  size,  with  effusions  into  the  splenic  pulp  accompanied 
by  high  fever  lasting  for  several  weeks,  and  in  the  tliird  variety 
the  spleen  is  not  so  large,  but  the  fever  is  a  very  early  symptom.  In 
this  type  a  relapsing  fever  occurs,  but  Eiselt  asserts  that  the  spirilla 
of  Obermeier  have  not  been  found  in  the  blood  in  these  cases,  and 
that  they  are  truly  typhoid,  because  of  the  intestinal  lesions  found 
in  some  of  the  fatal  cases  in  the  latter  forms  of  the  disease  and 
by  reason  of  the  source  of  infection. 

Hoffmann  found  9  cases  of  infarction  of  this  organ  in  250  autop- 
sies, and  7  of  these  died  in  the  fourth  week.  Griesinger  believed 
infarction  of  the  spleen  to  be  present  in  7  per  cent,  of  fatal  cases, 
and  Liebermeister  believed  these  lesions  to  be  responsible  for  the 
production  of  peritonitis  in  many  cases  where  this  condition  arises 
independently  of  perforation.  Sometimes  the  infarction  results  in 
the  formation  of  a  large  abscess  filling  the  greater  part  of  the  organ. 
Liebermeister  records  a  case  in  wliich  after  death  from  general 
peritonitis  the  spleen,  wliich  was  three  times  its  natural  size,  was 
found  transformed  into  a  huge  abscess,  making  seven-eio;hths  of 
its  bulk.     No  perforation  of  the  abscess  wall  had  occurred. 

The  Genito-urinary  Tract  in  the  Well-developed  Stage  of  the 
Disease. — It  has  already  been  pointed  out  in  an  earlier  chapter 
that  acute  nephritis  may  usher  in  an  attack  of  typhoid  fever,  but 

1  Eiselt.     La  Semaine  Medicale,  August  27,  1S91. 


116  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

such  an  occurrence  is  very  uncommon,  and  the  development  of  a 
nephritis  in  the  hiter  stages  of  the  disease  is  ahnost  as  rare.  In 
such  a  case  the  presence  of  albmnin,  casts,  blood  cells,  and,  per- 
haps, pure -blood  in  the  urine  may  make  a  diagnosis  easy. 

Cm'ionsly  enough,  the  amount  of  blood  in  the  urine  in  such 
cases  is  no  guide  to  their  severity,  because  unless  the  flow  of  blood 
has  been  sufficiently  great  to  decrease  the  patient's  strength  it  does 
not  represent  the  degree  of  renal  involvement.  Further,  it  is  to 
be  remembered  that  in  some  cases  in  wliicli  there  is  marked  ha?ma- 
turia  the  autopsy  fails  to  reveal  marked  renal  change,  or  instead 
of  nephritis  an  infarction.  Such  cases  have  been  reported  by 
Homburo-er  and  bv  Duckworth,  bv  Sorel,^  and  bv  other  writers. 

o  •  »  «. 

In  cases  in  wliich  there  are  tube  casts  and  other  signs  of  acute 
diffuse  nepliritis,  the  prognosis  may  be  grave.  Osier  reports  two 
cases  w'hich  died.  Amat  had  ten  deaths  in  twelve  cases,  while 
Waffner  had  five  consecutive  recoveries. 

Hemorrhagic  nephritis  has  been  recorded  by  Stevens-  in  associa- 
ation  with  ursemic  symptoms.  Relief  came  by  a  profuse  hemor- 
rhao-e  from  the  bowels,  and  recoverv  occurred. 

Rostoski^  reports  two  cases  of  renal  typhoid  fever  as  follows: 

A  patient  was  admitted  with  severe  headache  and  bronchitis. 
The  urine  contained  blood,  albumin,  and  epithelial  casts.  A  few 
days  later  the  characteristic  rash  and  diarrhoea  appeared.  Widal's 
reaction  gave  a  positive  result.  In  this  case  the  nephritis  passed 
into  the  chronic  form  of  the  disease. 

A  woman,  a^ed  twentv-six  vears,  was  admitted  with  urine  con- 
taining  blood  and  albumin,  and  subsequendy  epithelial  casts. 
About  three  wrecks  after  the  commencement  of  the  disease  Widal's 
reaction  was  obtained,  and  two  days  later  typhoid  bacilli  were  cul- 
tivated from  the  urine.  Five  days  afterward  the  patient  had 
severe  abdominal  pain,  with  vomiting,  and  moderate  collapse.  On 
the  next  day  the  whole  of  the  abdomen  was  exquisitely  tender. 

1  These  authors  are  quoted  by  Hewetson  in  his  article  "  The  Urine  and  the  Occur- 
rence of  Renal  Complications  in  Typhoid  Fever,"  in  vol.  iv,  Johns  Hopkins  Hospital 
Reports. 

2  Stevens.     University  Medical  Magazine,  May,  1896. 

3  Rostoski.  These  cases  are  also  to  be  found  in  an  abstract  in  the  British  Medical  Journal 
of  April,  1899. 


GENirO  UUINAIIY  TRACT  IN  77/ A'  1)EVFJ/)I'I:I)  STAC  I:      \  17 

A  lilHc  Inter  :iii  ini|);iir<'<l  |)ciciis-,i()ii  iiolc  Wii^  iii;m|c  out,  over  tlu; 
ilcocaccal  rcf^ioii,  due,  as  it,  was  thought,  to  a  lofalizefi  scrou-,  peri- 
tonitis.  The  patient  gradually  iinjyrovefJ,  and  subsequently  made 
a  good  recovery.  The  ease  was  very  obscure  at  first.  The  pres- 
ence of  an  acute  ncpliiitis  was  only  recognized  thirteen  days  after 
the  onset  of  the  disease.  The  diagnosis  from  tuberculosis,  malig- 
nant endocarditis,  and  sepsis  was  very  rliffieult.  It  was  only  when 
Widal's  reaction  was  I'oiukI  in  the  fourtli  week  of  the  disease  that 
the  nature  of  the  case  became  (,)bvious.  The  temperature  was  not 
characteristic,  but  the  spleen  was  enlarged.  The  signs  of  perito- 
nitis appeared  about  the  fiftieth  day,  shortly  after  the  administra- 
tion of  a  clyster;  previously  there  had  been  no  intestinal  symp- 
toms. The  patient  also  recovered  from  this  complication.  Ro.s- 
toski  expresses  the  opinion  that  in  every  case  of  nephritis  which 
might  be  classed  as  idiopathic,  but  which  has  a  high  temperature, 
the  urine  should  be  examined  for  typhoid  bacilli  and  the  blood 
tested  for  Widal's  reaction. 

In  147  cases  admitted  to  the  German  Hospital  of  Philadelphia^ 
in  1898  from  the  United  States  Army,  albuminuria  was  present 
in  57.1  per  cent.,  and  true  nephritis  in  25.2  per  cent. 

True  nephritis  due  to  typhoid  infection  is  rare.  The  mortality 
rate  in  cases  of  tliis  kind  is  high — 33.3  per  cent.  (Hewetson). 
Wlien  death  ensues  it  is  caused  by  the  general  toxaemia  or,  less 
frequently,  because  of  the  development  of  such  complications  as 
pyelitis  or  abscess  of  the  kidney. 

Late  in  the  disease  or  in  convalescence  a  transient  nephritis 
may  develop,  associated  with  pretibial  oedema. 

Aside  from  diffuse  nepliritis  due  to  enteric  fever,  we  find  that  the 
kidneys  may  be  the  seat  of  suppm'ative  processes,  developing,  as  a 
rule,  in  the  form  of  multiple  or  miliary  abscesses.  These  abscesses 
are  due  usually  to  infection  of  the  organ  by  the  ordinary  pyogenic 
cocci  and  rarely  to  infection  by  the  bacillus  of  Eberth.  The 
latter  condition  has,  however,  been  recorded  by  Flexner,  who  has 
studied  two  cases  of  focal  abscesses  in  the  kidney,  and  found  by 
careful  differentiation  that  tliis  bacillus  was  the  sole  cause  of  the 

1  Philadelphia  Medical  Journal,  February  25,  1899. 


118  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

lesion.  The  urine  in  these  cases  was  albuminous  and  contained 
blood  cells,  and  at  times  casts  covered  with  leukocvtes. 

Horton  Smith'  found  in  the  postmortem  examination  of  289  cases 
of  typhoid  fever  ojily  one  case  in  which  there  were  sup})urating foci 
in  the  kidney,  but  Comiell'-  states  that  in  the  laboratory  of  pathology 
of  the  New  York  Hospital  minute  focal  necroses  are  frecjuently 
found  in  the  kidneys  of  patients  that  have  died  of  typhoid  fever. 

There  are  few  clinical  symptoms  whicli  can  be  used  to  diagnosti- 
cate such  lesions  other  than  the  simis  shown  l)v  the  urine. 

Albu^iixuria. — A  very  excellent  paper  on  the  important  subject 
of  all)uminuria  in  typhoid  fever  has  been  published  by  Hewetson, 
in  which  he  has  exhausted  the  literature.  He  quotes  Guimet  as 
having  met  \\dth  albuminuria  in  children  21  times  in  45  cases,  and 
Mason  as  having  met  with  it  in  CO  out  of  G7G  cases,  of  wliich  45 
recovered  and  15  died.  At  the  Johns  Hopkins  Hospital,  Hewetson 
found  it  in  1G4  out  of  229  cases,  but  tube  casts  were  found  in  only 
103  of  these.  He  also  found  that  the  period  in  which  albumin  ap- 
peared in  the  urine,  so  far  as  he  could  tell,  was  in  the  first  week 
in  66  per  cent,  of  the  cases;  in  the  second  week  in  75  per  cent.; 
in  the  third  week  in  41.6  per  cent.;  wliile  in  the  fourth  week  it 
occurred  in  35  per  cent.  A  very  interesting  thing  in  this  connection 
is  the  fact  that  in  none  of  these  cases  were  there  any  objective  signs 
of  renal  disease,  any  ursemia,  or  oedema. 

Albuminuria  occurred  in  31  per  cent,  of  190  cases  in  Nurem- 
berg, according  to  Zinn,^  and  epithelium  and  hyaline  casts  in  21 
per  cent. 

The  urine  in  typhoid  fever  is  nearly  always  decreased  in  amount 
in  the  acute  stage,  and  is  usually  darker  in  hue  than  normal,  con- 
taining a  high  percentage  of  solids.  Small  amounts  of  albumin 
may  be  in  it  wthout  indicating  nephritis,  but  if  casts  are  present 
much  albumin  is  usually  found,  and  the  diagnosis  of  nephritis  is 
justified.  About  70  per  cent,  of  all  cases  of  this  fever  show  albumi- 
nuria at  times,  but  even  if  mild  nephritis  develops,  the  prognosis 
is  not,  as  a  rule,  grave.     Thus  in  the  Johns  Hopkins  Hospital, 

'  Horton  Smith.     Lancet,  1899,  i,  1349. 

-  Connell.     -American  Journal  of  the  Medical  Sciences,  May,  1909. 

2  zinn.     Miineliener  medicinische  W^ochenschrift,  February  14,  1899. 


(lENITO-UiaNAIiV  TliACT  IN  'rilh:  DEVKLOI'El)  STACr:      \\'.\ 

albuminuria  occurred  in  104  out  of  229  cases,  nix  I  (iifjc  casts  in 
103;  altogether  21  out  of  these  229  cases  had  (Icfinile  nephritis, 
and  10  had  red  cells  in  the  urine;  2  suffered  Iroin  lierriorrli;t;^ic 
nephritis,  but  only  5  of  these  cnses  died,  ;iiid  none  of  these  fiom 
the  renal  difTieulty. 

Rostoski^  foinid  albumin  j;resent  in  the  uiine  205  times  in  ;j40 
cases,  or  in  59.2  per  cent.  In  37  of  these  205  cases  the  albumi- 
nuria was  marked  and  hyaline  and  epithelial  casts  were  fcjund, 
proving  the  presence  of  an  infectious  nephritis. 

Hanford"  has  also  shown  that  albuim'nuria  may  occnr  in  ty|>hoid 
fever  without  possessing  any  grave  prognostic  import,  but  the 
gravity  of  the  case  is  in  direct  ratio,  as  a  rule,  to  the  cjuantity  of 
the  albumin.  Among  patients  with  large  amounts  of  albumin  the 
mortality  is  usually  very  high. 

Pyuria  and  bacilluria  arise  in  typhoid  fever  either  from  the 
kidneys  (very  rarely)  or  from  the  bladder.  Pyuria  varies  in  severity 
from  the  presence  of  a  few  pus  cells,  which  are  found  with  diffi- 
culty by  the  microscope,  to  marked  pyuria.  The  best  study  of 
this  subject  is  probably  that  of  Blumer.^  He  found  no  less  than 
16  cases  in  60  typhoid  fever  patients,  or  nearly  17  per  cent.  In 
some  the  pus  was  found  present  when  the  patient  came  under 
observation;  in  4  cases  it  appeared  between  the  tenth  and  fifteenth 
days;  in  3  between  the  twenty-second  and  twenty-eighth  days,  and 
in  1  on  the  forty-second  day.  Its  duration  varied  from  a  few 
days  to  three  months.  In  nearly  all  his  cases  the  pus  was  present 
in  full  amount.  In  some  it  gradually  increased;  in  others  it 
came  in  large  amount  at  once.  The  organisms  found  in  the 
urine  were  the  colon  bacillus,  the  typhoid  bacillus,  Staphylococcus 
albus,  and  an  unidentified  coccus.  The  colon  bacillus  was  found 
in  seven  cases;  the  typhoid  bacillus  twice,  and  the  staphylococcus 
once.  These  observations  are  important,  because  it  has  been  said 
by  Karlinski,  of  Krakow,  that  he  has  found  the  Eberth  bacillus 
in  no  less  than  50  per  cent,  of  all  cases.     In  all  probability  the 

1  Rostoski.  Munehener  medicinisclie  Wochensclirift ,  February  14,  1899.  Tliis  valuable 
paper  contains  references  to  the  literature  of  the  subject.  The  title  of  the  paper,  '  'Zur 
Kenntniss  die  Typhus  Renalis,"  refers  to  nephritis  complicating  typhoid  fever,  and  not  that 
of  the  form  of  onset  called  '  'nephrotyphus." 

-  Hanford.     London  Lancet,  April  28,  1889. 

^  Blumer.     Johns  Hopkins  Hospital  Reports,  1895,  vol.  v. 


120  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

differentiation  between  the  colon  bacillus  and  that  of  typhoid  fever 
was  not  properly  carried  out.  IJrownlee  and  Chapman^  have 
reported  iive  cases  of  pyelitis  during  the  disease,  this  condition 
usually  being  associated  with  nephritis. 

No  ease  of  pyelitis  due  to  the  bacillus  of  Eberth  alone  had  been 
reported  up  to  1S9S,  which  is  interesting  in  view  of  the  well- 
known  fact  that  this  bacillus  was  frequently  found  in  the  kidney 
after  death,  and  was  always  found  in  the  renal  lymphomata  of  this 
disease.  Typhoid  bacilli  Avere  found  in  the  kidney  of  one  case  at 
autopsy.  Konjajeff-  asserts  that  the  discovery  of  this  bacillus  in 
the  urine  indicates  the  development  of  these  lymphomata  in  the 
kidney;  but  this  is  improbable,  since  post-typhoidal  pyelitis,  not 
due  to  this  organism,  of  a  membranous  type  may  develop  and  be 
associated  with  a  membranous  cystitis. 

Richardson^  found  typhoid  bacilli  present  in  the  urine  of  nine 
out  of  twenty-eight  cases  of  typhoid  fever.  They  were  always  in 
large  numbers  and  in  practically  pure  cultures,  and  they  appeared 
in  the  later  stages  of  the  disease  and  persisted  in  most  cases  far 
into  convalescence.  Their  presence  is  nearly  always  associated 
with  albuminuria  and  casts. 

In  a  still  later  report  Richardson'*  reports  sixty-six  further  cases, 
of  which,  fourteen  showed  the  presence  of  bacilli  in  the  urine. 

ConnelP  studied  a  series  of  fifty  consecutive  cases  of  typhoid 
fever,  and  found  the  typhoid  bacillus  in  the  urine  of  eleven  cases. 
This  work  was  very  carefully  carried  out,  there  having  been  made 
323  examinations.  This  writer  has  also  made  a  careful  study  of 
the  literature  of  typhoid  bacilluria.  He  collected  a  "series  of  cases 
of  typhoid  fever,  sufficiently  examined  to  detect  any  lasting  bacil- 
luria, and  of  such  a  type  and  at  such  a  recent  period  as  to  make  the 
identifications  of  the  bacilli  trustworthy."  He  took  631  cases  to 
make  up  his  series,  of  which  150  showed  typhoid  bacilli  in  the 
urine,  and  he  draws  the  conclusion  that  typhoid  bacilli  can  be 
detected  in  the  in-ine  of  24  per  cent,  of  all  cases  of  typhoid  fever. 

It  may  be  stated  therefore  that  the  bacilli  invade  the  urine  and 

1  Brownlee  and  Chapman.     Glasgow  Medical  Journal,  December,  190G. 

*  Konjajeff.     Centralblatt  fur  BakterioloKie,  1889. 

5  Richardson.     Journal  of  Experimental  Medicine,  1898,  vol.  iii.         '  Ihid.,  1899,  vol.  iv. 

°  Connell.     American  Journal  of  the  Medical  Sciences,  May,  1909. 


fjENITO^UUINARY  TRACT  IN  Tllh:  I ) i:V  1:1.01' FJ)  STAf.h'      ]2] 

9,re  detected  most  IVc((ii('iitly  in  llic  dccliniiio-  shiffc  of  ilic  disoa.se, 
at  id)()nt  the  tiiiK!  when  the  teinpeiatun;  Ijeeoines  jiorimil,  ■,i\t\\()U^]\ 
they  may  be  found  earlier  in  tlie  (Jisciise,  ii.s  reported  l)y  Seliichhold/ 
Jacobi,^  Lesieur  and  Machand,''  and  Coimell. 

The  bacilli  usually  persist  in  the  urine  for  several  weeks,  and 
disappear  spoutMueously  in  most  cases.  There  are,  however,  a 
cousideral)le  number  of  cases  that  persist  for  months  and  even 
years,  causing  the  patient  to  be  a  serious  menace  to  the  public 
health.  Rousig'  examined  the  lu-ine  of  10  CJcrman  soldiers  who 
had  returned  from  the  siege  of  Pekin  six  months  after  their  attacks 
of  typhoid  fever,  and  in  one  case  found  the  urine  swarming  with 
typhoid  bacilli.  Houston''  found  typhoid  bacilli  present  in  pure 
culture  in  the  urine  of  a  patient  three  years  after  his  typhoid  fever, 
and  Youno-'s  case  was  known  to  have  bacilli  in  his  urine  for  nine 
years.®  Liebtrau  reports,  among  other  cases  of  typhoid  carriers, 
one  who  after  nine  years  showed  typhoid  bacilli  in  the  urine.' 

Petruschky^  has  estimated  that  in  one  case  a  single  cubic  centi- 
meter of  urine  contained  170,000,000  typhoid  bacilli,  and  Gwyn* 
estimated  500,000,000  per  cubic  centimeter  in  another  case. 

Horton  Smith^**  examined  the  urine  of  seven  typhoid  patients, 
with  three  positive  results,  and  he  remarks  that  the  micro-organisms 
may  be  so  numerous  as  to  cause  distinct  turbidity  of  the  urine. 

Petruschky^^  has  pointed  out  that  the  bacillus  of  typhoid  is  often 
found  in  the  urine  some  weeks  after  the  temperature  is  normal. 

To  sum  up  the  evidence  from  a  clinical  point  of  view,  w^e  find 
that  pyuria  in  typhoid  fever  is  not  a  grave  sign,  but  that  if  the 
specific  bacillus  is  found  in  the  urine  the  patient  must  be  kept 
under  observation  until  it  disappears,  since  it  may  lead  to  serious 
mischief. 


1  Schichhold.     Deut.  Arcliiv  f.  klin.  Med.,  1899,  Lxiv.  505. 

2  Jacobi.     Deut.  Archiv  f.  klin.  Med.,  1902,  Ixxii,  442. 

'  Leiseur  and  Marchand.     Hygiene  g^n.  et  appliq.,  Paris.  1906,  i,  546. 

*  Rousig.     Infect.-Krankheit.   der  Harnorgans.   Berlin,    1S9S. 

«  Houston.     British  Jledical  Journal,  1899,  i,  79. 

8  Young.     Johns  Hopkins  Hospital  Reports,  1900,  \in.  401. 

'  Liebtrau.     Arbeit,  a.  d.  Kaiser.  Gesundheitsamte,  1906.  xxiv,  341. 

s  Petruschky.     Centralblatt  fiir  Bakteriologie,  1898,  xxiii. 

s  Gwyn.     Johns  Hopkins  Medical  Bulletin,  1900,  viii,  389. 

10  Horton  Smith.     Transactions  of  Medical  and  Surgical  Society,  London,  1897 

11  Petruschky.     Centralblatt  fiir  Bakteriologie,  1892,  xiv. 


122  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

Pyonephrosis  has  been  recorded  by  Fernel'  aiul  ]\Iurray.- 
The  patient  of  Fernel,  who  had  previous  to  typhoid  fever  suffered 
from  intermittent  hydronephrosis,  developed  a  fluctuating  abdom- 
inal tumor,  which  proved  to  be  a  pyonephrosis  containing  a  pure 
culture  of  the  l)acillus  of  Eberth. 

Cystitis. — It  is  surprising  that,  despite  the  abundant  literature 
concerning  the  presence  of  the  Bacillus  typhosus  in  the  urine  of 
patients  ill  of  typhoid  fever,  as  well  as  during  convalescence  from 
this  disease,  so  few  cases  of  cystitis  are  caused  by  this  bacterium. 

Vincent,^  in  1200  cases  of  typhoid  fever,  noted  only  two  cases  of 
acute  cystitis  due  to  the  typhoid  organism,  which  appeared  during 
convalescence.  Rousig*  reported  a  case  in  w^hich  the  patient,  a 
man,  aged  fifty-three  years,  noted  during  convalescence  from 
typhoid  fever  that  his  urine  was  milky  in  appearance.  Several 
months  after  this  he  began  to  have  vesical  pain  and  frequency  of 
urination.  Cultures  from  the  urine  of  this  patient  revealed  a  pure 
culture  of  the  typhoid  bacillus.  A  suprapubic  cystotomy  was  per- 
formed and  the  bladder  was  found  contracted,  the  mucous  mem- 
brane greatly  inflamed  and  the  site  of  many  ulcerations.  At  autopsy 
both  kidneys  were  found  to  contain  many  small  abscesses.  Young^ 
has  reported  a  remarkable  case  in  which  the  patient  suffered  from  a 
cystitis  due  to  the  typhoid  bacillus  for  nine  years  following  an  attack 
of  typhoid  fever.  During  this  time  typhoid  bacilli,  in  pure  culture, 
were  repeatedly  found  in  the  urine.  Cystoscopic  examination 
revealed  the  presence  of  a  chronic  inflammation  of  the  mucosa  and 
numerous  small  ulcers. 

Brown"  records  a  case  with  similar  cystoscopic  and  bacterio- 
logical findings,  apparently  arising  from  the  use  of  an  infected 
catheter,  and  Houston^  also  reports  a  case  of  severe  cystitis  occurring 
during  typhoid  fever.    Sato^  has  also  reported  a  case  of  this  kind. 

In  Houston's  case  of  typhoid  cystitis,  a  woman,  aged  thirty-five 

'  Fernel.     Gazette  des  Hopitaux,  1897,  No.  10. 

-  Murray.     Quoted  by  Connell,  American  Journal  of  the  Medical  Sciences,  May,  1909. 

2  Vincent.     Stances  de  la  soc.  de  biologic,  1901,  liii,  275;  also  loc.  cit.,  1903,  Iv,  365. 

*  Rousig.     Infect.-Krankheit.  der  Harnorgans,  Berlin,  1898. 

'  Young.     Johns  Hopkins  Hospital  Reports,  1900,  viii,  401. 

0  Brow-n.     Medical  Record,  1900,  Ivii,  405. 

^  Houston.      British  Medical  Journal,  1899,  i,  79. 

8  Sato.     Hefukwa  kid  Hiuiokikwa  Zarshi,  Tokyo,  1907,  vii,  521. 


THE  ALJMKNTAUY  CANAL   IN   Tlll<:  /j/:V h'LOrh'D  STArj/'J     ]2'.>, 

yeiirs,  li.ul  siid'cfcd  from  cyslili.s  lor  ;i  lon^  [xTiod  of  (ii/H-;  llx- 
urine  was  stroii^'ly  acid,  turbid,  coiilaincd  a  small  fjiianlily  of 
albumin  as  wt'U  us  s<|ii;uii()ms  (■[)i(J)cliiim,  lcuk(j(:yl<,s,  and  som*: 
bacteria.  A  bacillus  witli  all  the  (-liaraclcristics  of  that  of  typhf^id 
was  cultivated,  and  hci*  blood  oav(;  a.  marked  (yplioid  icaction  of 
l.Ol,  A  second  exaininalion  of  her  urine  piodneed  similar  resnlts; 
although  the  patient  was  kept  in  the  hospilal  for  six  weeks,  there 
were  no  other  typhoid  symptoms  and  no  febrile  movement. 

In  all  probability  this  is  a  case  in  which  the  disease  had  been  so 
mild  at  some  previous  time  as  not  to  attract  attention,  but  the 
bladder  infection  had  persisted. 

Polyuria. — Profuse  urinary  flow  is  sometimes  seen  in  the  lafler 
part  of  defervescence  and  in  convalescence.  It  may  amount  to 
ninety  ounces  in  twenty-four  hours  for  many  days.  This  has  usually 
no  great  significance.  Fussell,  Carmany,  and  Hudson^  have  reported 
a  case  of  polyuria  during  typhoid  fever  of  a  very  unusual  type.  This 
patient  early  in  the  disease  was  observed  to  be  passing  large  quan- 
tities of  urine,  and  this  continued  through  the  course  of  the  disease 
and  into  convalescence.  Many  nervous  symptoms  were  also  pres- 
ent. These  writers  review  the  literature  of  this  unicjue  complica- 
tion. Wilson^  has  also  reported,  within  a  few  weeks  of  the  report 
above  mentioned,  a  case  who  showed  this  symptom  all  through  an 
attack  of  typhoid  fever.  The  greatest  amount  passed  in  any  one 
day  was  215  ounces.  Patients  suffering  from  this  condition  have 
been  known  to  pass  10,000  c.c.  in  twenty-four  hours.  Hutchinson^ 
has  reported  a  case  of  diabetes  mellitus  following  t^'phoid 
fever. 

The  Alimentary  Canal  in  the  Developed  Stage. — Refer- 
ence has  already  been  made  to  pharyngeal  typhoid  lesions  in  the 
stage  of  onset.  A  more  or  less  severe  inflammation  of  the  pharynx 
is  to  be  found  in  nearly  all  severe  cases  of  typhoid  fever  if  it  is 
sought  for,  and  it  is  sometimes  sufficiently  marked  to  cause  the 
patient  to  complain  of  his  throat.  Letulle,^  under  the  name 
"pharyngotyphoid"    has    recently  called   particular  attention   to 

1  Fussell,  Carmany,  and  Hudson.     Medical  News,  September  17,  1904. 

2  Wilson.     Jledical  News,  November  19,  1904. 

^  Hutchinson.     British  Medical  Journal,  January  14,  1S9S. 
■•  LetuUe.     La  Presse  Medicale,  October  15,  1907. 


124  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

cases  in  which  there  is  severe  inflaniination  of  the  ])harvii\',  and  he 
cites  a  case  which  showed  marked  ulceration,  due  to  tlie  ty])hoid 
bacillus,  upon  the  uvula  and  other  ulcers  upon  the  pillars  of  the 
fauces. 

Ouskow/  in  a  study  of  439  autopsies  representing  6513  cases  of 
typhoid  fever,  noted  that  in  the  majority  of  the  cases  the  pharynx 
was  reddened  and  covered  in  part  Avith  a  membrane  difiiciilt  to 
remove.  In  only  four  cases  were  the  ulcers  of  any  depth,  and  in  two 
cases  there  was  a  phlegmonous  process.  As  a  rule,  the  lesions  con- 
sist in  congestion  of  the  mucous  membrane  with  swelling  of  the 
glands  in  this  part  of  a  character  similar  to  that  met  with  in  other 
parts  of  the  alimentary  canal.  Pharyngeal  symptoms  may  develop 
in  convalescence  (which  see);  sometimes  membranous  pharyn- 
gitis coming  on  in  the  third  week  may  cause  death,  and  Taupin- 
records  a  case  in  which  it  asserted  itself  in  a  case  of  typhoid  fever 
complicated  w^ith  measles. 

Gerloczy,^  a  physician  of  Budapest,  has  recorded  a  case  of  a 
girl,  aged  fourteen  years,  wdio  suffered  from  typical  typhoid  fever 
with  swelling  of  the  submaxillary  glands  and  the  development  of 
a  membrane  in  the  pharynx.  The  case  had  pulmonary  oedema 
and  membranous  pharyngitis,  laryngitis,  and  bronchitis. 

Not  only  are  inflammatory  changes  found  in  the  pharynx  in  this 
stage  of  typhoid  fever,  but  also  in  the  oesophagus,  where,  of  course, 
they  are  apt  to  be  more  moderate  than  in  the  pharynx  because  of 
the  lack  of  lymphoid  tissue.  Usually  swelling  of  the  glands  in  the 
mucous  membrane  is  to  be  found  on  inspection.  As  the  disease 
progresses  these  changes  may  become  ulcerative  and  severe. 
In  Baer's^  interesting  account  concerning  83  cases  of  typhoid  fever 
w^ith  unusual  distribution  of  the  ulcers,  there  were  ten  instances 
of  ulcers  in  the  oesophagus.  MitchelP  has  reviewed  this  subject, 
and  states  that  in  56  autopsies  in  the  Johns  Hopkins  Hospital, 
representing  between  700  and  800  cases  of  typhoid  fever,  oesopha- 
geal ulceration  occurred  but  once,  although  the  oesophagus  was 

1  Ouskow.     Archives  des  Sciences  Biologique,  1893,  T.  2,  No.  1. 

-  Taupin.     Journal  des  Connaissances  McSd.  Chir'urgicale,  1839. 

^  Gerloczy.     Deutsche  med.  Wochenschrift,  April  14,  1893. 

■*  Baer.     American  Journal  of  the  Medical  Sciences,  May,  1904. 

5  Mitchell.     Studies  in  Typhoid  Fever,  No.  3  Johns  Hopkins  Bulletin. 


THE  ALIMENTARY   CANAL  IN   THE   l)EVE[J  il'ED  ST  ACE      125 

always  ciU'cl'iilly  cxjimiiK-d.  Louis' jiiid  Jciijkt"  1i;i\c  seen  f;i-,c.s  of 
typhoid  ulceration  of  the  (I'sophagus,  and  iloderer  and  Wagner 
have  seen  a\sophan;itis,  as  have  also  Kichhorsf^  anrl  lieirner,  and 
again,  ChaiiHer  and  Cornil  have  d('SCTil)ed  a  coinHlifin  of  infih ra- 
tion of  the  mucous  membrane  of  iIh;  ovsofjhiigus  v\idi  a  fonn;itiori 
of  miliary  abscess.  These  changes  will  be  fV^nnd  discussed  in  the 
chapter  dealing  witli  the  stage  of  convalescence. 

Stomach. — Symptoms  peculiar  to  the  stomach  are  comparatively 
rarely  met  with  in  typhoid  fever,  unless  dietetic  errors  have  caused 
them,  or  unless  by  the  excessive  use  of  drugs  or  stimulants  its  func- 
tions become  perverted.  On  the  other  hand,  when  gastric  symptoms 
arise,  either  as  the  result  of  the  causes  just  named,  or  because  of 
some  unusual  feature  of  the  disease,  they  are  apt  to  be  not  only 
annoying  but  difficult  of  control.  Aside  from  moderate  gastric 
catarrh  due  to  the  fever  and  associated  with  a  condition  of  insuffi- 
cient and  inefficient  gastric  juice,  which  is  peculiarly  marked  in 
these  cases,  the  unusual  symptoms  vary  from  hiccough,  which  is 
really  an  affection  of  the  diaphragm  produced  by  a  reflex  from  the 
stomach  in  many  cases,  to  vomiting,  and  from  discomfort  in  the 
epigastrium  to  severe  pain.  Disregarding  the  moderate  form  of 
hiccough  seen  so  often  accompanying  ordinary  indigestion,  we 
now  and  again  meet  with  cases  in  w-hich  this  symptom  becomes 
not  only  annoying  but  exceedingly  dangerous,  in  that  it  causes 
rapid  exhaustion  and  failure  of  the  heart,  apparently  by  some 
associated  vagal  neurosis,  over  and  above  the  great  drain  upon 
the  patient's  strength.  Numerous  cases  are  on  record  in  which 
this  complication  has  resulted  in  great  danger  or  even  in  death. 

Vomiting  in  typhoid  fever  may  be  an  unimportant  or  very  grave 
complication.  Often  it  occurs  because  of  indigestion  or  irritability 
of  the  stomach,  and  stops  as  soon  as  the  diet  is  altered  or  the  quality 
and  mode  of  using  stimulants  is  changed.  Its  gravity  depends 
largely  upon  its  persistency,  because  if  it  ensues  on  taking  food  the 
patient  speedily  dies  from  lack  of  nourishment;  and  if  it  is  of  the 


1  Louis.     Reclierches  anatomiques,  patliologiques  et  tlierapeutique  sur  la  fievre  typhoid 
(1841).     Translated  by  Henry  I.  Bowdich,  Part  2,  Art.  2. 

-  Jenner.     Edinburgh  Monthly  of  Medical  Science,  1S50,  vol.  10,  p.  311. 

2  Eichhorst.     Handbueh  der  specielleu  Patliologie  uud  Therapie,  Funfte  auflage,  1S97. 
Band  iv,  416. 


12o  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

incessant  type,  resembling  the  status  epilepticus  in  its  constancy 
and  spasmodic  character,  the  patient  retching  incessantly,  whether 
the  stomach  is  empty  or  not,  death  is  imminent  because  of  direct 
exhaustion..  Such  cases  are  not  common,  but  when  they  occur  the 
prognosis  must  be  very  grave.  Sometimes  it  would  seem  as  if  tlie 
vomiting  was  caused  by  a  neurosis  or  by  poisoning  of  the  vomiting- 
centre  in  the  medulla. 

Still  more  rarely  in  typhoid  fever  the  vomiting  arises  from  ulcer 
of  the  stoniacli. 

Hemorrhage  from  the  stomach  is  very  rare  in  typhoid  fever  and 
is  almost  unknown.  Pepper  states  that  typical  typhoid  ulcers  may 
be  found  in  the  stomach,  and  from  them  it  is  possible  that  hemor- 
rhage may  occur.  Soltau  Fenwick^  has  recorded  a  case  in  which 
typhoid  gastric  ulcers  nearly  perforated,  and  another  in  which 
they  did  perforate,  but  peritonitis  was  prevented  by  the  liver 
becoming  adherent  to  the  stomach.  Death  occurred  in  this  case 
from  profuse  hemorrhage  from  one  of  these  ulcers.  We  have 
only  met  w^ith  one  case  in  which  h?ematemesis  took  place.  A 
w^oman,  aged  twenty-eight  years,  who  was  seized  with  a  very 
severe  attack  of  the  disease,  died  at  the  end  of  the  first  w^eek  imme- 
diately after  vomiting  a  large  amount  of  blood  and  passing  a 
great  quantity  by  the  bowel.  No  autopsy  was  held,  and  in  all 
probability  the  blood  had  entered  the  stomach  from  the  small 
bowel.     The  following  cases  are  those  of  Fenwick's: 

A  girl,  aged  eight  years,  succumbed  during  the  third  week  of 
enteric  fever.  On  examination  of  the  stomach,  four  well-defined 
ulcers  were  found  in  the  pyloric  region,  one  of  which  presented  a 
loosely  adherent  slough.  The  edges  of  the  ulcers  were  sharply 
defined  and  somewhat  undermined,  while  their  bases  were  situated 
in  the  submucous  and  muscular  coats  of  the  organ.  On  micro- 
scopic examination  the  lymphoid  tissue  of  the  stomach  was  found 
to  be  enormously  increased,  and  the  supposition  that  the  ulcers 
originated  in  disease  of  the  solitary  glands  was  confirmed  by  the 
appearance  of  the  smallest  one.  From  these  facts  it  would  appear 
that  under  certain  circumstances  disease  of  the  solitary  gastric 

'  Fenwick.     Disorders  of  Digestion  in  Infancy  and  Childliood,  1897,  p.  386. 


THE  ALJMKNTAIIY  CANAL  IN   Till':  DEVELOPED  STAGE     yjl 

glands  iDiiy  ^'ivc  rise,  to  ii  I'onn  of  |»cir(jr;iliii;^  iilrcr  of  iIk-  t(,in;i()i 
whic;h  closely  rescinblcs  the  idiopatliie  type  of  the  disease. 

"A  girl,  aged  thirteen  years,  was  admitted  into  the  hos}>it;il  with 
the  symptoms  of  tyj)lioid  fever  of  eight  diiys*  diirafion.  \'orm'ting 
occurred  once  or  twice,  hut  there  was  no  coiiiplniiil  of  c|)iu-a.stric 
pain.  At  the  end  of  the  fourth  week  of  the  disease,  when  the  tem- 
perature had  begun  to  decline,  the  patient  was  suddeiily  seized 
with  severe  hsematemesis,  after  which  she  became  unconscious  and 
died.  At  the  necropsy  the  anterior  wall  of  the  stomach  was  found 
to  be  adherent  to  the  under  surface  of  the  liver.  Scattered  over 
the  inner  surface  of  the  stomach  there  were  numerous  shar[>Iy 
defined  ulcers,  the  largest  of  which  was  about  the  size  of  a  fioiin. 
The  edges  were  tliin  and  undermined  and  the  base  was  formed  by 
the  muscular  or  peritoneal  coat.  In  the  first  part  of  the  duodenum 
there  was  an  ulcer  of  a  similar  character,  while  the  whole  of  the 
intestine,  from  the  jejunum  to  the  rectum,  was  riddled  with  typical 
typhoid  ulcers." 

Osier  has  reported  the  following  cases  to  Keen : 

"John  M.,  aged  forty  years,  was  admitted  August  21,  1890, 
with  a  history  of  illness  of  some  weeks'  duration.  The  chief 
symptoms  were  headache  and  fever.  The  blood  examination  was 
negative.  There  was  a  very  definite  rose-colored  eruption.  The 
temperature  was  never  high,  not  rising  above  103°.  On  the  27th  he 
vomited,  and  in  one  of  the  attacks  he  brought  up  a  dark  greenish- 
brown  fluid  containing  red  blood  corpuscles  in  a  condition  of  disin- 
tegration, and  a  clot  of  blood  about  3  by  2  cm.  in  diameter.  On  the 
29th,  30th,  and  31st  the  stools  were  very  dark  in  color,  and  evidently 
contained  blood,  and  several  times  he  vomited  very  dark  material. 
He  became  very  anaemic,  but  made  a  good  recovery. 

"Alberta  C,  colored,  aged  twenty  years,  admitted  June  14,  1S94. 
This  patient  was  admitted  in  the  third  week  of  the  disease.  On  that 
afternoon  she  had  had  a  hemorrhage  from  the  bowels.  She  was 
bleeding  quite  freely  on  admission.  Between  6  and  8  p.m.  she  had 
five  large  stools  of  almost  pure  blood,  with  clots.  Tlu-oughout  the 
following  day  she  was  extremely  feeble;  temperature  was  normal; 
patient  was  delirious.  On  June  16  there  was  no  further  bleeding 
from  the  bowels.    Toward  evening  the  patient  was  delirious,  and 


12S  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

her  condition  was  verv  had.  At  S.lo  p.m.  she  vomited  100  c.c.  of 
dark  bloody  fluid,  which  contained  blood  coloring  matter  and  red 
blood  corpuscles.    She  sank,  and  died  that  eveninp;. 

"Dr.  H,,  aged  twenty-two  years,  admitted  January  9,  1S9G.  He 
had  a  very  severe  attack,  with  persistent  fever,  which  resisted  the 
baths.  These,  though  given  from  the  outset,  did  not  check  the  onset 
of  quite  active  delirium.  On  January  25,  about  the  eighteenth 
day  of  the  disease,  the  abdomen  was  a  good  deal  distended;  there 
was  moderate  diarrhoea  and  less  delirium.  He  seemed  to  be  doing 
very  well.  He  had  had  no  special  gastric  symptoms.  In  the  after- 
noon he  quite  suddenly  sprang  up  in  bed  and  vomited  a  quantity 
of  dark  blood.  The  amount  was  diflficult  to  estimate,  as  it  went 
all  over  the  bedlinen.  Part  of  it  was  collected,  and  Dr.  Parsons 
estimated  the  amount  to  be  about  200  c.c.  It  contained  much 
debris  and  red  blood  corpuscles.  The  staining  on  the  sheets  was 
quite  red.  On  the  26th  the  temperature  was  between  103°  and  104°, 
and  in  the  afternoon  at  3.05  he  vomited  between  200  and  300  c.c. 
of  almost  pure,  bright  red  blood.  The  pulse  became  more  rapid, 
but  these  two  hemorrhages  did  not  appear  to  have  any  injurious 
influence.  His  temperature  gradually  fell  and  was  normal  on  the 
31st.  He  made  an  uninterrupted  recovery  after  a  most  severe 
attack." 

Weiss^  records  a  case  of  a  soldier,  aged  twenty-two  years,  who 
died  from  profuse  gastric  hemorrhage  about  the  beginning  of  the 
third  week  of  typhoid  fever.  This  was  preceded  by  intestinal 
hemorrhage.  As  no  statement  is  made  as  to  whether  a  postmortem 
confirmed  the  diagnosis,  the  case  is  to  be  considered  as  a  doubtful 
one.  INIillard^  reports  a  case  of  profuse  hsematemesis  two  days 
before  death  from  typhoid  fever.  The  autopsy  revealed  extensive 
ulceration  of  the  stomach  extending  to  the  cardiac  orifice.  Nicholls^ 
was  able  to  find  only  four  instances  of  haematemesis  in  his  study  of 
over  100  cases  of  hemorrhagic  typhoid  fever. 

Intestines. — One  of  the  first  facts  which  attracts  our  attention 
in  regard  to  the  intestine  during  typhoid  fever  is  that  many  cases  of 

1  Weiss.     Wiener  med.  Presse,  1888. 

-  Millard.     Quoted  by  Brouardel  and  Thornot,  La  Fifevre  Typhoid,  Paris,  1895. 

^  Nicholls.     Montreal  Medical  Journal,  June,  1896. 


THE  ALIMKNTAIiY   CANAL  [N    Till-:   DEV la.OI'Hh   STAr;h'      |2!) 

this  disease  are  rccor-f led  in  vvliicli  ;i(  llic  ;iiilo|),sy  no  si^nsof  tyj^lioid 
fever  could  be  found  in  the  intestines.  Some  of  diese  Iiave  not 
been  as  carefully  studied  as  tliey  should  be,  bul  odicis  are  fcrf.'dtily 
authentic.  Thus,  Du  (-azar  has  recorded  two  instances  in  which 
the  closest  postmortem  inspection  failed  to  sfiow  intestinal  lesions, 
yet  typhoid  bacilli,  which  res|)ondc(l  to  all  tests,  were  found  in  the 
spleeji,  and  the  symptoms  of  the  (h'sease  wen;  present  in  life.  'J'he 
spleen,  mesenteric  glands,  and  ki(hieys  were  swollen  iind  congested. 
Bacilli  of  typhoid  fever  were  ol)tained  not  only  from  an  abscess 
in  the  spleen,  but  also  from  vegetations  in  the  mitral  valves  and 
from  a  hemorrhagic  placpie  on  the  surface  of  die  brain.  Banti^ 
and  Karlinski^  have  reported  similar  cases  not  so  well  j^roved. 
Ivarlinski's  cases  numbered  three. 

Nichols  and  Keenan'  have  reported  nine  cases  of  t\phoid  fever 
without  intestinal  lesions.  So,  too,  Flexner  and  Harris'^  have 
recorded  such  a  case,  and  Chiari  and  Kraus  met  with  seven 
instances  out  of  nineteen  cases  of  typhoid  fever  in  five  months. 

GoodalP  reports  two  cases  of  enteric  fever,  fatal  during  the  third 
and  fifth  week  respectively,  in  which  there  was  no  intestinal  ulcera- 
tion. The  first  patient  was  a  boy,  aged  thirteen  years,  who  had  been 
ill  a  fortnight  when  admitted  to  the  hospital;  the  second  was  a  man, 
aged  thirty  years,  who  had  already  been  ill  ten  days.  Both  of  them 
showed  all  the  clinical  evidences  of  typhoid  fever,  and  in  each  there 
was  a  swelling  of  Peyer's  patches  without  ulceration.  Similarly, 
Fagge^  records  the  case  of  a  man,  aged  thirty-three  years,  who  had 
typhoid  fever,  and  whose  only  lesion  in  the  intestine  consisted  of 
one  ill-defined  purplish-red  patch  about  the  size  of  a  shilling, 
situated  a  foot  above  the  valve  and  a  little  higher  up;  another 
patch  with  a  brush  surface,  which  was  visible  only  when  it  was 
examined  under  water.  So,  too,  in  November,  1880,  ^Nloore  showed 
before  the  Patholoo-ical  Societv  of  Dublin  a  case  of  enteric  fever  in 


1  Du  Cazal.     Bulletin  et  Soc.  Mdm.  M^d.  des  Hop.,  1S93,  p.  243,  and  Le  Bulletin  Medi- 
cale,  April  16,  1894. 

-  Banti.     Archiv.  Italiennes  de  Biol.,  December,  1887. 

2  Karlinski.     Wiener  med.  Woclienschrift,  1S91,  pp.  470  and  511,  and  1897.  ii.  1850. 
*  Nichols  and  Keenan.     Montreal  Medical  Journal,  1898.  xxvii,  9. 

'  Flexner  and  Harris.     Johns  Hopkins  Hospital  Bulletin,  1897,  viii,  p.  259. 
^  Goodall.     Clinical  Society's  Transactions,  1897,  vol.  xxx. 
^  Fagge.     Pathological  Soeietj-'s  Transactions  for  1876. 

9 


130  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

which  there  was  no  disease  of  the  glands  of  the  ileiiin,  while  the 
spleen  was  extremely  large,  soft,  and  friable,  and  Fever's  patches 
were  noted"  appearing  less  distinct  than  usual,  though  with  no 
hyperannia,  and  did  not  present  the  shaven-beard  appearance. 
Sydney  Phillips  reported  to  the  Clinical  Society,  in  1891,  two 
cases,  fatal  after  the  third  week,  with  no  ulceration.  Goodall 
points  out  that  out  of  sixty-three  autopsies  he  has  held  in  cases  of 
enteric  fever  at  the  Eastern  Hospital  he  has  met  with  absence  of 
ulceration  in  five  cases;  in  two  of  these  death  took  place  early,  on 
the  eighth  and  tenth  days;  in  two  others,  as  the  result  of  some  com- 
plication, on  the  thirty-second  and  seventy-third  days. 

Other  cases  have  been  recorded  by  Beatty,^  Church,  and  Coup- 
land. 

Again,  Hodenpyle,-  of  New  York,  has  contributed  a  paper  upon 
this  subject,  reporting  a  case  of  undoubted  typhoid  fever  in  which 
the  intestinal  lesions  were  absent.  Brunschwig^  has  also  recorded  a 
case  of  this  kind,  and  HoeffeP  has  done  likewise,  there  being  in  his 
case  but  slight  swelling  and  reddening  of  a  few  Beyer's  patches. 
Schultz  claimed  to  have  met  with  21  cases  out  of  300  autopsies  of 
this  disease  without  the  characteristic  ulcers  in  the  ileum;  but  there 
is  doubt  as  to  the  correctness  of  his  statement. 

Bryant^  reports  the  case  of  a  child,  aged  twenty-one  months,  who 
died  of  typhoid  fever  at  the  end  of  the  third  week,  and  whose  blood 
l)efore  death  gave  the  Widal  test.  The  autopsy  showed  that  the 
heart  weighed  one  and  one-half  ounces,  and  appeared  to  be  normal. 
The  arteries,  mouth,  pharynx,  oesophagus,  and  stomach  were  nor- 
mal in  appearance.  The  ileum  also  appeared  to  be  normal.  There 
was  no  ulceration,  and  the  Beyer's  patches  were  not  swollen  or 
discolored.  Nowhere  in  the  intestine  could  any  sign  of  recent 
typhoid  ulceration  be  found,  and  there  was  not  any  appearance 
suggesting  a  healing  or  healed  typhoid  ulcer.  The  peritoneum 
W'as  normal.  The  liver  weighed  sLxteen  ounces,  and  had  a  normal 
appearance.    The  gall-bladder  and  pancreas  were  normal.    The 

I  Beatty.     British  Medical  Journal,  June  16,  1897,  p.  148. 
-  Hodenpyle.     British  Medical  Journal,  December  2.5,  1897. 

'  Brunschwig.     '  'Is  the  Lesion  of  Peyer's  Patches  a  Constant   SjTnptom  of  Typhoid 
Fever?"     Strasburg  Thesis  for  1870. 

*  Hoeffel.     Gazette  M(5dicale  de  Strassburg,  1871,  No.  14,  p.  167. 

*  Bryant.     Briti.sh  Medical  Journal,  April  1,  1899. 


Till':  ALIMENTARY   CANAL  IN    TIIL  DLV LLOI'LD  HTACL      \:>,\ 

mesenlcric  ^liuids  were  iniicli  (•iil;ii<i;c(l,  ;iimI  IV'li.  v^ry  soft;  on  sec- 
tion tliey  prcscnUid  ;i,  f)inkisli-^ray  f;olor,  iind  uj)i>f!Lrf(l  to  he  in  a 
condition  of  acute  in/lammation;  tli('re  was  no  sign  of  suppuration 
or  caseation  in  any  of  them.  Tiie  suprarenal  capsules  were  normal 
Tiie  kidneys  weighed  llnce  ounces;  they  were  \y.\\c.  'V\\<'  sf>lcen 
was  a  little  enlarged. 

That  the  ease  was  one  of  (nic  lyphoid  fever  is  proved  Ijv  the 
results  of  careful  hactei-iological  study  of  the  tissues.  As  Bryant 
well  says: 

"Nothing  unusual  was  anticipated  before  the  necropsy  took 
place.  It  was  expected  that  the  usual  typical  ulceration  of  the 
Peyer's  patches  of  the  lower  part  of  the  ileum  would  be  found,  and 
great  surprise  was  expressed  when  no  swelling,  discoloration, 
ulceration,  or  other  abnormalities  whatsoever  could  be  detected 
in  the  Peyer's  patches,  solitary  glands,  or  mucous  membrane  of 
any  part  of  the  intestine.  I  thought  at  first  an  erroneous  diagnosis 
had  been  made,  and  suggested  that  the  symptoms  might  have 
been  accounted  for  by  the  bronchopneumonia  which  was  found, 
although  the  character  of  the  pyrexia  was  against  this  view.  After 
finding  the  enlarged  mesenteric  glands,  I  suggested  that,  after  all, 
it  was  most  probably  an  anomalous  case  of  typhoid  fever  without 
any  lesion  of  the  intestinal  mucous  membrane.  Cultures  from  the 
enlarged  mesenteric  glands  yielded  an  almost  pure  culture  of  the 
Bacillus  typhi  abdominalis.  The  slight  clotting  of  the  milk  inocu- 
lated from  the  first  broth  culture  taken  directly  from  the  glands 
was  probably  due  to  a  slight  contamination  with  the  Bacillus  coli 
communis.  It  will  be  noticed  that  coagulation  did  not  take  place 
until  after  fortv-eight  hours,  and  then  it  was  onlv  slight.  I  could 
not  find  any  colonies  of  the  Bacillus  coli  communis  on  the  gelatin 
plates,  although  I  looked  and  carefully  examined  for  them,  so  that 
if  present  originally  the  number  must  have  been  insignificant. 
The  bacillus  obtained  from  the  gelatin  plates  gave  the  character- 
istic positive  and  negative  reactions  of  the  Bacillus  typhi  abdomi- 
nalis, namely,  did  not  produce  gas  in  any  media,  did  not  cause 
milk  to  clot,  did  not  produce  indol,  did  not  produce  acid,  did  not 
liquefy  gelatin,  and,  further,  these  bacilli  obtained  from  a  recent 
culture  and  treated  with  both  50  per  cent,  and  5  per  cent,  serum 


V') 


132  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

from  a  ty})lu)itl  patient,  and  also  from  an  immunized  rabbit, 
t'lumj)ed  together  in  a  manner  eliariieteristie  of  the  Baeiihis  typhi 
abdoniinahs." 

Thiie/  ill  1889,  described  a  case  in  wliich  (huing  hfe  the  fever 
was  of  a  recurrent  type,  and  the  spleen  was  found  to  be  considerably 
enlarged.  At  the  necropsy  slight  swelling  only  of  Peyer's  patches 
was  found.  The  Bacillus  typhi  abdoniinahs  is  stated  to  have  been 
obtained  from  the  spleen  and  kidneys,  but  is  not  sufficiently  identi- 
fied as  such. 

Vaillard,-  in  1890,  reported  the  case  of  a  young  soldier  who  died 
after  an  illness  of  three  days'  duration.  The  chief  symptoms  were 
headache,  epistaxis,  pyrexia,  constipation,  retraction  of  the  neck, 
and  coma.  At  the  necropsy  congestion  of  the  lungs  and  meninges 
was  found,  but  there  was  no  intestinal  lesion.  The  Bacillus  typhi 
abdoniinahs  was  obtained  by  culture  from  the  spleen,  lungs,  and 
spinal  cord;  streptococci  were  also  obtained  from  the  spleen  and 
meninges. 

(niarnieri,^  in  1892,  described  a  case  of  typhoid  fever  which 
during  life  presented  the  characteristic  symptoms  of  the  disease. 
No  intestinal  lesion,  however,  was  found  at  the  necropsy,  but  the 
Bacillus  typhi  abdominalis  was  obtained  by  culture  from  the  biliary 
passages,  liver,  and  spleen. 

^'incent,^  in  1893,  described  the  case  of  a  man,  aged  thirty-five 
years,  who  died  about  the  twelfth  day  after  the  onset  of  a  severe 
ilhiess  characterized  by  pyrexia,  diarrhoea,  purpura,  and  coma. 
At  the  necropsy  the  Peyer's  patches  were  found  to  be  normal;  the 
mucous  membrane  of  the  intestine,  however,  was  congested.  The 
spleen  weighed  230  grams;  the  mesenteric  glands  were  not 
enlarged;  bilateral  pulmonary  congestion  was  found.  The  Bacil- 
lus typhi  abdominalis  and  streptococci  were  obtained  from  the 
spleen,  liver,  kidney,  and  heart. 

Osier  mentions  a  somewhat  similar  case.  The  patient  was  a  man, 
aged  sixty  years,  who  was  admitted  into  the  hospital  under  his  care. 

'  Thue.     Jaliresbericht  iiber  die  Fortschritte  (Baumgarten),  1889,  196. 
-  Vaillard.     La  Semaine  Mddicale,  March,  1890,  p.  94. 

'  Guarnieri.     Rivista  G^n<?rale  Italiana  di  Clinica  Medica,  1897;  Baumgarteii's  Jalires- 
bericht, 1897,  234. 

*  Vince/it.     Annales  de  I'lnsfitut  Pasteur,  February,  1893. 


77//';  AUMJ'JNTAnV   CANAL  IN    Till':  DEV ELOI'KI)  HTACE      \\>;.>, 

He  IijmI  Ix'cii  ill  for- ;il)()ti(,  Iwo  iiioiilhs,  iiiHJ  on  iidmissioii  ujisfoiiiK] 
(,()  l)(^  .sullVriii^'  IVoiii  slioidicss  of  hrcjilli,  iiiHJ  prcsciilcd  sij^ii.s  of 
j)i)eum()iii{i  airectiii^  tlic  lovvcc  lolx;  of  (lie  \\\^\i  liiii^.  I)cii(li  (of>k 
place  twciity-four  hours  after  admission.  A  diagnosis  of  senil<; 
pneumonia  was  made  during  life.  At  the  necropsy  the  lower  lolx; 
of  the  right  lung  showed  fr-csii  |)ii('ninonia  passing  on  to  ;i  rondition 
of  giingrene.  There  was  wo  inlestina!  lesion.  The  organs  wen; 
submitted  to  a  bacteriological  exann"iiation  by  Flexner,  and  ]>nre 
cultures  of  tlie  Bacillus  typhi  abdominalis  were  f)b(ain(d  tVoni  thf- 
lungs  and  spleen. 

Mettenheimer^  records  an  epidemic  of  typhoid  fever  (jcciuring 
in  the  army  in  which  in  twenty-one  cases  the  intestinal  lesions 
were  entirely  limited  to  the  colon.  Banti^  and  Karlinski'  have 
also  reported  cases  of  this  character. 

A  case  is  recorded,  in  Cheadle's'  service  at  St.  Mary's  Hospital, 
of  a  child,  aged  three  years,  who  died  of  typhoid  fever,  and  at  the 
necropsy  no  ulceration  was  present  in  the  intestine  and  Beyer's 
patches  appeared  to  be  normal.  Beatty'  records  two  cases  with  a 
similar  condition  present. 

Baer**  has  investigated  the  reports  of  a  number  of  these  cases, 
and  came  to  the  conclusion  that  there  were  but  28  cases,  including 
the  two  reported  by  himself,  that  were  investigated  in  such  a 
manner  as  to  be  worthy  of  being  placed  upon  record  as  cases  of 
true  infection  with  the  Bacillus  typhosus  and  not  revealing  at  autopsy 
any  sign  of  intestinal  ulceration.  It  is  our  opinion  that  there  is  a 
far  e-reater  number  of  cases  of  this  kind  than  is  generallv  believed. 

DiARRHGEA  is  Speedily  ceasing  to  be  a  fairly  constant  symptom  of 
the  disease.  As  a  matter  of  fact,  it  is  in  a  very  large  proportion 
of  cases  supplanted  by  constipation  from  the  beginning  to  the  end 
of  the  malady,  although  classical  worlvs  nearly  all  regard  looseness  of 
the  bowels,  amounting  to  three  or  four  stools  a  day,  as  the  usual 
condition  in  average  attacks.    This  is  particularly  the  case  in  the 


1  Mettenlieimer.     Jaliresberichte  iiber  die  Gesammte  Med.,  1872,  Bd.  2,  p.  235. 

=  Banti.     La  Riforma  M^dica,  1887,  p.  1448. 

'  Karlinski.     Wiener  med.  Wocheii.,  1891,  pp.  470  and  511. 

^  Cheadle.     The  Lancet,  Julj^  31,  1897,  p.  254. 

5  Beatty.     British  Medical  Journal.  January  16,  1897. 

'^  Baer.     American  Journal  of  the  Medical  Sciences,  May,  1904. 


134  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

typhoid  fever  of  chiUiren,  in  whom  constipation  occurs  even  more 
commonly  than  in  adults. 

Students  very  often  seem  to  have  the  idea  that  the  absence  of 
diarrhoea  in  a  given  case  is  an  important  point  against  the  diagnosis 
of  typhoid  fever.  On  the  contrary,  it  is  so  often  absent  that  its 
absence  is  of  no  negative  vakie  whatever,  aUhough  its  presence 
possesses  more  importance.  Certainly,  constipation  is  much  the 
more  frequent  state  as  we  meet  the  disease  in  Philadelphia,  and  as 
Osier  well  points  out,  diarrhoea  occurs  in  Baltimore  in  not  more  than 
30  per  cent,  of  his  cases,  and  is  an  active  form  in  only  about  12 
per  cent.  So,  too,  we  find  that  in  Curschmann's^  clinic,  from  1880 
to  1892,  diarrhoea  was  met  with  in  only  25  per  cent,  of  the  cases 
(1626  cases).  Phillips  tells  us  that  of  200  consecutive  cases  in  St. 
IMary's  Hospital,  London,  diarrhoea  occurred  in  115,  constipation 
in  48,  but  in  many  of  these  cases  diarrhoea  had  been  set  up  by  a 
purge  given  before  the  diagnosis  was  made,  so  that  his  experience 
in  no  way  militates  against  the  statistics  just  cited. 

In  the  ^Maidstone'  epidemic  50  per  cent,  of  the  cases  were  con- 
stipated.   Murchison  found  it  in  93  out  of  100  cases. 

"When  the  diarrhoea  is  excessive,  amounting  to  ten  and  twenty 
stools  a  day,  the  diet  has  usually  been  faulty  in  the  extreme,  or 
ulceration  of  the  large  bowel,  amounting  to  a  dysenteric  state,  is 
generally  present. 

The  character  of  the  stools  is  usually,  in  the  cases  with 
moderate  diarrhoea,  quite  typical,  but  green  stools  in  typhoid 
fever  are  occasionally  met  with.  They  have  been  referred  to  by 
Dreschfeld  in  AUbutt's  System  of  Medicine,  the  discoloration 
being  seen  during  convalescence.  QuilP  has  recorded  a  case  in 
which  bright-green  material  was  vomited  on  the  eighth  day,  and 
later  the  patient  passed  bright  green  fluid  stools.  There  w'as  great 
pain  in  the  back.  Garrod,  Drysdale,  and  Kanthack*  report  three 
cases.  The  stools  resembled  chopped  parsley,  and  the  liquid  por- 
tion of  the  stools  when  filtered  off  contained  biliverdin,  which  was 
probably  responsible  for  the  discoloration  of  the  excreta. 

1  Curschmaim.     Deutsche  Archiv  f.  klin.  Medicin,  1895. 

2  Poole.    Guy's  Hospital  Reports,  1898.    (Wrongly  labelled  on  cover,  1896.) 

3  Quill.     British  Medical  .Journal,  October  22,  1898,  p.  12.52. 

■*  Garrod,  Drysdale,  and  Kanthack.    St.  Bartholomew's  Ho-spital  Reports,  vol.  xxxiii. 


THE  ALIMENTARY   CANAL  IN    THE  l>EVEI/)l'EI)  ^TAdE      \'.>,ri 

The  ii(!.\'t  poiiil,  (()  he  considered  in  (lii-,  eonnc-l  ion  i^  wliellier 
diarrhcra  is  a  sign  of  inild  or  severe  iiif'eelion.  The  consensus  of 
opinion  seerns  to  be  that  diarrhasa  is  usually  more  active  in  serious 
cases.  Whether  this  is  an  instance  of  "purging  as  an  effort  iit 
eHmination,"  a  favorite  theory  witli  those  vvlio  are  fond  of  using 
purgatives  and  so-calhid  intestinal  antiseptics,  with  the  idea  tlint 
by  so  doing  they  eliminate  poisons  and  prevent  their  ffjrmafion,  or 
whether  it  is  a  manifestation  of  severe  ulceration  of  the  bowel  with 
an  associated  catarrh,  is  difficult  to  determine.  Ord'  agrees  with 
the  view  that  diarrh(jca  is  usually  associated  with  ulceration,  and 
his  opinion  has  been  confirmed  by  the  autopsies  he  ha.s  seen. 
Peabody  is  diametrically  opposed  to  this  view.  'J'hat  Ord's  view 
is  not  correct  seems  proved  by  the  fact  tliat  advanced  ulceration 
is  often  found  in  cases  which  have  not  had  diarrhrjea,  and  cases  of 
marked  diarrhoea  are  seen  in  which  the  autopsy  does  not  reveal 
much  intestinal  ulceration.  In  Bryant's  case,  already  quoted, 
diarrhoea  was  active,  yet  no  intestinal  lesions  were  found.  In  all 
probability  diarrhoea  is  neither  indicative  of  a  severe  nor  a  light 
attack  in  many  cases,  although  if  it  be  violent  the  exhaustion  pro- 
duced by  the  discharges  may  seriously  imperil  tlie  patient's  chances 
of  recovery.  This  view  is  strongly  advocated  by  Sydney  Phillips, 
who  regards  diarrhoea  as  a  symptom  adding  danger  to  the  progress 
of  the  typhoid,  as  he  believes  it  prevents  absorption  of  nutrin-tent 
and  drains  the  body  of  fluid;  he  is  therefore  distinctly  opposed 
to  the  so-called  "purgative  treatment." 

Tympanites. — Closely  allied  to  this  question  of  diarrhoea  is  that 
of  the  gravity  of  tympanites,  a  condition  almost  always  present 
at  some  time  during  the  course  of  even  the  mildest  attacks,  and, 
as  a  rule,  less  frequently  present  in  cases  with  active  diarrhoea  than 
in  those  with  constipation,  although  a  great  accumulation  of  gas  in 
the  intestines  is  also  met  with  in  some  instances  in  which  the 
bowels  are  moving  quite  frequently.  As  a  rule,  such  passages  are 
small  in  quantity,  and  are  usually  quite  fetid.  The  gravity  of 
tympanites  as  a  symptom  depends  chiefly  upon  its  ability  to  do 
harm,  and  this  harm  is  in  direct  proportion  to  the  degree  of  its 
interference  by  pressure  with  the  functions  of  the  thoracic  and 

1  Ord.    Transactions  Association  of  American  Physicians,  ISSS,  vol.  iii. 


136  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

abdominal  organs;  tliat  is.  the  strain  put.  In  the  distention.  uj)on 
those  parts  of  the  bowel  wall  which  are  weakened  bv  ulceration 
and  in  danger  of  perforation  from  this  cause,  or  to  the  stretching 
of  the  floor  of  an  ulcer,  thereby  inducing  hemorrhage.  The 
degree  of  tympanites  is  not  always  a  definite  guide  as  to  the 
damage  it  may  do.  It  may  be  extreme  in  one  case  and  moderate 
in  another,  and  yet  in  the  first  instance  very  little  harm  seems  to  be 
done  by  it,  Avliile  in  the  second  instance,  either  by  reason  of  cardiac 
susceptibility  or  peculiar  application  of  the  pressure,  the  injury  may 
be  grave.  While,  therefore,  the  evil  effects  of  tympanites  are, 
as  a  rule,  in  direct  ratio  to  its  degree,  cases  are  continually  met 
with  in  which  it  is  excessive  and  yet  in  which  no  bad  results  ensue. 
"When  the  tympanites  is  very  excessive  constij)ation  may  restilt  from 
paralytic  distention  of  the  gut,  and,  on  the  other  hand,  the  paralysis 
or  relaxation  of  the  bowel  may,  by  preventing  peristalsis,  permit 
the  accumulation  of  gas. 

Pain  in  the  abdomen  is  very  distinctly  a  symptom  of  the  early 
stages  of  the  disease,  and  in  many  cases  is  due  to  gas  produced  by 
fermentation.  The  pain  is  usually  wandering,  is  not  constantly 
in  one  spot,  and  if  it  becomes  fixed  it  probably  depends  upon  a 
localized  complication.  Pressure  upon  the  belly  wall  is  apt  to 
increase  the  pain.  It  is,  however,  a  noteworthy  fact  that  later  on  in 
the  disease,  when  tympanites  is  often  excessive  and  the  bowel 
greatly  distended,  there  is  apt  to  be  little  or  no  pain  even  on  press- 
ure, perhaps  because  the  atony  of  the  muscular  coat  of  the  bowel 
prevents  griping,  and  the  tenderness  of  the  first  stage  of  swelling 
and  inflammation  is  supplanted  by  a  state  of  local  and  general 
nervous  torpor. 

Hemorrhages. — The  frequency  with  which  hemorrhages  occur 
varies  greatly  in  different  epidemics,  independently  of  any  specific 
line  of  treatment  over  and  above  rest  in  bed.  Lack  of  such  rest 
at  any  stage  of  the  malady  certainly  predisposes  the  patient  to  this 
accident. 

A  considerable  amount  of  statistical  evidence  also  indicates  that 
the  use  of  cold  bathing  as  a  therapeutic  measure  in  this  disease 
increases  the  frequency  of  this  complication. 

In  861  cases  of  this  disease  without  the  cold  bath,  in  Lieber- 


X 


THE  ALIMENTARY   CANAL  IN    TIIH   l>i:V HLOI'LI)  STAdL      ]:>,7 

meister's  clinic  ui  B;i,scl,  IiciihmiIi;i;;cs  occiirrcd  72  tiiiir-s,  f^r  X.4 
per  cent.  Griesinger  met  with  32  ca,se,s  in  'ioo,  oi-  in  ').'.',  jxt  fcnl.; 
and  TiOiiis  found  them  in  5.0  per  cent.,  exfludinn  mild  cases;  Hci'^r, 
in  ]()2()  cases,  n)ct  with  ihein  in  5.5  jht  c(  ni.  TIk-  yoinifjcr  \\  iin- 
derlieh  has  recorded  OS  cmscs  of  lyplioid  I'cvcr  wilhoiit  ilic  hath, 
with  heniori'hage  in  2  cases,  or  ahout  2  per  cent.  KndV  I'onnd  in 
his  study  of  intestinal  hemorrhage  in  tyj>h(jid  fever  that  it  (jccurred 
in  4.24  per  cent,  of  cases,  and,  curiously  enough,  that  women  were 
more  frequently  attacked  than  men,  while,  on  the  other  hand,  more 
males  died  from  this  accident  than  females.  He  does  not  think  that 
the  prognosis  depends  directly  upon  the  amount  of  blfKjd  lost.  We 
find,  therefore,  that  in  1559  cases  treated  without  the  cold  hath 
there  were  00  hemorrhagic  cases,  or  5.2  per  cent. 

On  the  other  hand,  we  find  that  in  bathed  patients  AVunderlich, 
Jr.,  records  155  cases  with  16  hemorrhagic  patients,  or  10.3  per 
cent.  Immermann,  at  Basel,  records  146  cases  with  6  hemorrhages, 
or  4.1  per  cent.;  and  Liebermeister,  882  cases  with  45  hemor- 
rhages— 1183  cases,  or  6.8  per  cent. 

This  is  shown  best  by  the  following  table : 

Without  Bath. 

Cases.  Hemorrhages.  Per  cent. 

Liebermeister 861  72  8.4 

Griesinger 600  32  5.3 

Wunderlich,  Jr 98  2  2.0 

Total 1559  106  5.2 

With  Bath. 

Cases.  Hemorrhages.  Per  cent. 

Liebermeister 882                         55  6.2 

Immermann 146                           6  4.1 

Wunderlich,  Jr 155                         16  10.3 

Total 1183  77  6.8 

To  these  may  be  added:  In  America,  with  baths,  Wilson's  140 
cases  with  10  hemorrhages,  or  7  per  cent.;  Osier's  356  cases  with 
12  hemorrhages,  or  3.4  per  cent.^ 

It  is  interesting  to  note  in  this  connection  that  Fitz  places  the 
general  frequency  in  bathed  cases  at  5  per  cent,  and  Loomis  at 
5  per  cent.    It  is,  however,  only  fair  to  state  that  Goltdammer,  from 

1  Kraft    Centralblatt  f.  die  med.  Wissenschaften,  1893,  p.  137.         =  Only  299  were  bathed. 


+ 


138  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

nearly  20,000  cases,  concludes  that  the  baths  do  not  increase  hemor- 
rhages. Brand  claims  that  they  are  less  frequent  in  the  bath  treat- 
ment, as  do  also  Tripier  and  Bouveret;  but  Roland  G.  Curtin  tells 
us  that  upon  investigation  he  found  that  since  the  cokl-water  treat- 
ment has  been  instituted  the  number  of  hemorrhagic  cases  has  con- 
siderably  increased,  according  to  the  hospital  records  that  furnish 
his  data,  and  in  addition  the  mortality  of  the  hemorrhagic  cases  is 
largely  increased,  viz.,  from  five  in  seventeen,  less  than  one-half, 
to  twenty-five  in  forty-three  cases,  or  over  one-half;  and,  further, 
on  inquiry  he  found  that  in  two  of  his  tabulated  cases  the  hemor- 
rhage seemingly  took  place  while  the  patient  was  in  a  bath,  and  in 
one  case  immediately  after  a  bath.  . 

An  important  point  in  this  connection  is  the  question  as  to  the 
real  danger  to  the  patient  from  hemorrhage.  In  this  opinions 
greatly  differ.  Thus,  Fitz  tells  us  that  it  is  always  a  serious  symp- 
tom, but  rarely  fatal  in  private  life;  but  that  it  may  be  very  dis- 
astrous is  shown  by  the  fact  that  Liebermeister  mentions  49  deaths 
due  to  this  cause  out  of  127  deaths;  jNIurchison,  53  deaths  from 
hemorrhage  out  of  100  deaths;  and  Homolle,  44  per  cent,  in  498 
deaths.  Osier  asserts  that  death  occurs  in  from  35  to  50  per  cent, 
of  hemorrhagic  cases.  Out  of  Griesinger's  32  cases,  10  died,  7  of 
these  within  four  days  of  the  hemorrhage.  Liebermeister  tells  us 
that  among  his  own  cases,  38.6  per  cent,  died  when  they  had 
hemorrhage,  as  against  11  per  cent,  without  this  accident,  and 
Tyson  tells  us  that  the  7  per  cent,  of  mortality  in  his  cases  under  the 
bath  treatment  was  due  entirely  to  hemorrhage  or  perforation. 
It  is  evident  that  Osier's  percentage  is  about  correct. 

On  the  other  hand,  it  has  been  noted  by  some  clinicians  that  if 
the  hemorrhages  are  not  sufficient  to  produce  profound  exhaustion 
the  patient  often  does  better  after  their  occurrence  than  before. 
This  fact  was  at  one  time  insisted  upon  by  Dr.  Alfred  Stills,  and  it 
is  certainly  true  in  a  certain  proportion  of  cases. 

While,  as  a  general  rule,  the  danger  is  in  direct  ratio  to  the 
quantity  of  blood  lost,  recovery  may  occur  even  after  enormous 
quantities  have  been  passed.  We  have  had  a  case  which  recovered 
in  which  no  less  than  four  pints  of  blood  escaped  from  the  bowel 
at  one  bleeding,  and  Phillips  and  Wakefield,  in  1882,  saw  a  patient 


THE  ALIMENTARY  CANAL  IN    Till-:  hl'A' i:!/)!' i:i)  ST  ACL      \:',U 

who  bled  "(wo  cliiuiilxTriils"  ;iimI  recoverefl.  Miuli  (Icjjcufl  .  u|)')ii 
the  vitality  of  the  patient,  the  state  of  his  hlood  wlien  taken  ill, 
and  the  defi;r(;(^  to  whieh  (U'<^enerative  changes  icsiilting  from  the 
disease  have  taken  plitee  in  vital  organs. 

As  a  rule,  bleeding  from  the  bowel  in  tyjjiioid  f«\ci-  ii rises  from 
ulceration  of  an  arterial  twig,  but  cases  do  occur  where  blood  comes 
from  a  vein  which  has  been  opened  by  ulceration.  I'hilHps  has  re- 
corded such  an  instance. 

In  children  liemorrhages  from  the  bowel  are  more  nire  thiin  in 
adults  because  the  intestinal  lesions  are  not  sf)  marked,  as  a  ruie. 

As  an  illustration  of  how  rarely  intestinal  hemorrhage  c-ompli- 
cates  typhoid  fever  in  children,  the  statement  of  Simon  that  in 
twenty-one  years  of  practice  he  had  encountered  only  three  cases 
is  of  interest. 

Hillier,  on  the  other  hand,  met  with  hemorrhage  in  4  out  of  30 
cases.    The  younger  the  child  the  less  is  the  liability  to  this  accident. 

Perforation  of  the  Intestine. — Perforation  of  the  bowel  in 
typhoid  fever  bears  no  relation  to  the  severity  of  the  general  symp- 
toms. In  many  cases  the  reporting  physician  states  that  the  attack 
■of  enteric  fever  was  mild,  so  that  in  444  cases  collected  by  Fitz,  fully 
200  were  of  this  class.  In  14  of  the  cases  the  patients  belonged  to  the 
class  known  as  "walking  typhoid"  cases.  Thus,  Bennett^  reports 
the  case  of  a  man  who,  because  of  cardiac  dropsy,  was  admitted  to 
St.  Thomas'  Hospital.  He  was  purged  and  allowed  to  eat  heartily. 
Two  weeks  later  he  began  to  suffer  from  abdominal  pam,  and  the 
next  day  death  took  place  from  perforation  due  to  typhoid  fever. 
No  typhoid  symptoms  had  been  observed.  Finncane^  reports  a  case 
of  a  man  apparently  well  until  two  days  before  death,  when  t^'phoid 
perforations  occurred,  and  Ivleinwachter^  speaks  of  a  woman  who 
until  forty-eight  hours  before  her  death  was  at  business,  and 
who  was  suddenly  stricken  and  died  from  this  cause. 

When  perforation  occurs  the  symptoms  are  apt  to  be  ushered  in 
by  agonizing  pain,  usually  felt  in  the  appendicular  region,  which 
may  be  severe  enough  to  rouse  the  patient  from  a  considerable 

^  Bennett.    Transactions  of  the  Pathological  Society,  London,  1866,  x^•ii,  121. 

-  Finncane.    Lancet,  1SS9,  ii,  793. 

^  Kleinwachter.    Wienei-  med.  Press,  ISSO,  xxi,  337. 


140  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

degree  of  coma.  The  belly  'wall  .speedily  becomes  tense  and  then 
tympanitic,  and  all  the  symptoms  of  a  general  diffuse  peritonitis 
speedily  ensue.  Tlu»  jxdii  may,  however,  not  be  persistent,  but  pa.ss 
away  or  become  modihed,  as  the  peritoneal  inflammation  resulting 
from  the  escape  of  fecal  matter  becomes  more  and  more  septic. 
The  pulse  becomes  rapid  and  running,  and  collapse  may  speedily 
assert  it.self.  When  this  occurs  death  speedily  comes  on,  the  patient 
dying  in  a  few  hoiu's,  or,  again,  he  may  rally  and  survive  for  several 
days.  Early  death  is,  however,  the  more  common  result.  Thus  in 
the  collection  of  thirty-four  cases  made  by  Fitz,^  of  Boston,  37.3 
per  cent,  died  on  the  first  day,  29.5  per  cent,  on  the  second  day, 
and  83.4  per  cent,  in  the  first  week.  During  the  second  week  nine 
died,  in  the  third  week  four  died,  and  two  other  cases  lived  thirty 
and  thirty-eight  days  respectively. 

If  collapse  does  not  ensue,  the  rally  of  the  system  results  in  a  rise 
of  the  temperature  to  a  point  higher  than  before  the  accident,  and 
this  mo^■ement  is  often  accompanied  by  chills  and  rigors.  Usually 
by  the  second  or  third  day  the  peritoneal  symptoms  become  more 
and  more  marked,  the  condition  of  the  patient  more  and  more 
asthenic  and  depressed,  and  death  results  by  the  fourth  day  from 
a  general  peritonitis  Avith  toxaemia  from  the  absorption  of  toxic 
materials. 

In  other  cases  the  onset  of  the  perforation  is  insidious,  the 
belly  before  the  perforation  may  have  been  moderately  tym- 
panitic, but  now^  becomes  intensely  hard  and  swollen;  the  pain, 
which  in  some  cases  is  so  severe,  does  not  develop,  but  the  great  fall 
in  fever,  followed  by  a  rise,  and  this  again  by  rigors,  it  may  be,  give 
evidence  of  the  grave  accident  which  has  occurred.  The  pulse 
becomes  increasingly  rapid  and  running,  and  the  respirations  more 
and  more  costal  and  less  and  less  diaphragmatic,  until  the  patient 
sinks  out  of  life,  without  much,  if  any,  suffering,  in  much  the  same 
manner  as  one  sees  death  come  to  a  case  of  difi'use  septic  peritonitis 
due  to  a  pus-tube  or  an  old  appendicitis.  In  such  cases  the  perfora- 
tion is  usually  very  small,  and  is  so  surrounded  by  adhesions  that 
the  escape  of  the  intestinal  contents  is  very  gradual  and  insidious, 
infecting  the  peritoneum  without  the  escaping  fluid  being  copious 

1  Fitz.    Transactions  of  the  Association  of  American  Physicians,  1891 ,  vol.  vi. 


THE  ALIM/'JNTAIiV  CANAL   IN    TIIH  DIIV i:!/)!'!!!)  STACI-:      \\\ 

enough  to  produce  oi-c;i(  \y,\\\\  uv  widcsixciid  \\\\cc\'\i>\\.  '\'\\\>  po-^i- 
l)ili(y  of  jM'rronilioii  of  IIk-  bowel  l,;ikiii^  phice  insidiously  luis  l;e<M) 
emphasized  by  Sydi)ey  I'liillips,'  of  London.  'I'o  use  his  words: 
"In  some  cases  of  tyj)lioid  l'(\cr  where  nei\-e-fone  is  ;dre;id\-  lost 
a,nd  the  tympanitic  belly  is  soft  and  donghy,  perforation  and  after- 
peritonitis  may  occur  almost  insidiously  with  liflle  f)ain,  collaj>sc 
.signs,  or  alterations  in  temperature." 

The  first  ty})e  of  ease  is  illusli-ated  by  thai  of  a  medieid  sfudent 
nnd(>rthe  senior  author's  care,  who  while  eonvaleseing  from  a  very 
mild  attack  of  the  disease,  and  who  had  had  a  normal  tenifx-rature 
for  several  days,  was  seized  at  midnight  with  agonizing  pain  in  the 
epigastrium,  so  severe  that  he  implored  his  father  to  relieve  him 
or  kill  him  in  order  to  stop  his  suffering.  He  rapidly  passed  into 
collapse,  and  died  in  eight  hours. 

The  insidious  form  is  shown  by  the  case  of  a  man  who  came 
under  the  senior  author's  care  in  the  third  week  of  the  disease,  much 
exhausted  and  emaciated,  but  without  very  high  fever  at  any  time. 
At  the  end  of  the  fourth  week  he  seemed  to  be  doing  very  well,  but 
his  temperature,  which  had  been  approaching  the  normal,  suddenly 
rose  to  104°,  accompanying  a  chill;  his  belly  became  enormously 
distended,  his  breathing  became  more  and  more  costal,  and  he  died 
at  the  end  of  the  third  day  from  exhaustion  and  asthenia,  with  all 
the  physical  signs  of  perforation.  Both  of  these  cases  occurred 
before  the  days  of  operative  interference  in  this  condition. 

In  this  connection  it  is  interesting  to  note  that  a  sudden  fall  in 
temperature  is  not  a  symptom  necessary  to  the  diagnosis  of  intes- 
tinal perforation.  On  the  contrary,  there  are  many  cases  on  record 
in  which  a  rise  of  temperature  follows  this  accident.  Thus,  Lere- 
boullet^  states  that  in  all  the  cases  of  perforation  he  has  met  with 
there  has  been  a  rise,  not  a  fall,  and  he  quotes  Lorain,  Brouardel  and 
Thoinot,  Griesinger,  Amould,  Lemoine,  and  Homolle  as  agreeing 
with  him.    INIonod^  also  reports  such  a  case. 

Dieulafoy*  goes  so  far  as  to  assert  very  positively  that  peritonitis 

1  Phillips.     British  ISIedical  Journal,  November  12,  1S9S. 

-  LerebouJlet.  Academie  de  Medecine  de  Paris,  October  27  and  Xovember  3,  1896.  Dis- 
cussion of  a  paper  entitled  "De  I'lntervention  Chirurgicale  dans  les  Peritonites  de  la  Fievre 
Typhoide,"  by  Dieulafoy. 

5  Monod.    Ibid.  *  Dieulafoy.    Ibid. 


142  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

from  perforation  very  rarely  announces  itself  acutely,  with  sudden 
pain  and  marked  constitutional  symptoms.  On  the  other  hand,  its 
onset  is  generally  insidious.  The  sensibility  of  the  patient  is 
blunted,  the  peritoneal  infection  takes  place  slowly,  and  the  actual 
occurrence  of  perforation  may  escape  unnoticed. 

Although  such  cases,  due  to  pin-hole  perforation,  may  occur,  they 
cannot  be  considered  common. 

Fitz  mentions  56  cases  in  which  the  onset  of  symptoms  of  per- 
foration Avere  severe;  15  in  which  it  was  gradual  or  latent,  and  5 
in  which  there  was  no  sign  of  perforation.  Such  cases  as  the  last 
named  are  recorded  by  Laboulbdne,^  who  tells  us  that  there  was 
no  sign  of  perforation  save  a  chilliness  of  the  skin  and  a  slight  fall 
of  fever.  Barth"  makes  a  similar  report,  and  Jenner^  reports  a 
case  which  left  bed  on  the  ninth  day  and  died  some  hours  later  of 
perforation,  there  being  no  complaint  of  pain  made. 

What  the  ordinary  percentage  of  perforation  is  is  in  some  doubt, 
but  according  to  Murchison,^  it  is  in  the  neighborhood  of  3  per  cent. 
Schulz^  found  it  in  1.2  per  cent  of  3686  cases  of  typhoid  fever  in 
Hamburg  in  1886  and  1887,  and  Liebermeister"  in  1.3  per  cent,  in 
2000  cases  in  Basel  in  1865  to  1872.  Berg,  in  1626  cases,  met  with 
it  in  2.2  per  cent.,  and  this  is  about  the  percentage  reached  by 
Osier  in  cases  bathed  and  not  bathed. 

The  percentage  mortality  of  this  accident  is  very  high.  Of  1721 
autopsies,  the  percentage  was  11.3,  according  to  INIurchison. 
According  to  Holscher  it  was  found,  in  2000  Munich  cases,  114 
times  (5.7  per  cent.),  and  in  20  out  of  80  of  his  cases  which  ended 
in  death.  In  4680  cases  tabulated  by  different  writers,  Fitz  found 
the  proportion  to  be  6.58  per  cent.,  which  agrees  with  Holscher's 
statistics. 

Hoffmann  found  that  out  of  250  deaths  in  typhoid  fever,  20  were 
due  to  perforation. 

Perforation  is  very  much  more  frequently  seen  in  men  than  in 
women.    Fitz,  in  444  cases,  found  71  per  cent,  in  men  and  29  per 

>  Laboulbdne.    L'Union  M^dicale,  1S77,  xxiii,  389. 

2  Earth.    Bulletin  de  la  Soc.  Anat.,  1884,  lix,  142. 

3  Jenner.    Medical  Times,  1850,  xxii,  298. 

*  Murchison.    Continued  Fevers  of  Great  Britain. 

'  Sclmlz.    Centralblatt  fiir  Allegemeine  path.  Anat.,  1891 ,  ii,  289. 

'  Liebermeister.    Ziemssen's  Encyclopajdia,  vol.  i 


THE  ALIMENTARY   CANAL   IN    THE   hIA  IILOI'ED  STAf.L      \  y.', 

cent,  ill  woiiicii.  In  '21  ciiscs  of  |)crroi;ilioii  in  I5;i  :*l,  I.';  \vcr<-  nif-n 
and  0  were  women,  juid  (iriesinircr,  in  J 4  oases,  liud  10  men 
and  4  women.  Mureliison  also  i'onnd  In  24  cases  10  men  anrl  S 
women,  although  the  general  morlalil  y  of  t  he  disease  among  wfjiiifii 
was  sliglitly  higher  than  among  men.  So,  too,  Bristowe,  of  London, 
met  with  this  accident  in  men  in  11  cases  out  of  15,  and,  again, 
Nacke^  collected  lOG  perforation  cases,  in  which  72  were  in  men 
and  34  in  women. 

The  period  of  the  disease  in  wliicli  jx-rforation  most  commonly 
takes  place  is  at  the  end  of  the  third  week  or  latei-.  Thus,  in  twenty- 
two  cases  in  which  reliable  information  could  he  obtained  by 
Liebermeister,  perforation  took  place  at  the  end  of  the  second  week 
twice,  during  the  latter  half  of  the  third  week  six  times,  in  the 
fourth  week  twice,  in  the  fifth  week  six  times,  in  the  sixth  and 
seventh  weeks  twice  each,  and  later  than  this  twice.  Nacke  found 
it  84  times  out  of  185  cases  in  the  first  two  weeks,  and  00  later; 
62  out  of  117  cases  in  the  first  four  weeks  and  55  later. 

More  accurate  statistics  are  those  of  Fitz,  who  in  103  cases 
obtained  facts  shown  in  the  following  table : 


Date  of  Occurrence  in  Perforation. 


First   week 

Second 

Third 

Fourth 

Fifth 

Sixth 

Seventh 


Cases., 

4 
32 
48 
42. 
27 
21 

5 


Eighth 

Ninth 

Tenth 

Eleventh 

Twelfth 

Sixteenth 


Cafes 
week 3 


The  part  of  the  bowel  most  frequently  perforated  in  136  cases 
was  the  ileum  in  106  cases,  the  colon  in  12  cases,  and  the  vermi- 
form appendix  in  15  (Liebermeister).  Hoffmann-  tells  us  that  out 
of  20  cases  the  perforation  occurred  once  near  the  ileoci^cal  valve, 
four  times  at  four  to  six  inches  above,  nine  times  at  eight  to  twenty 
inches,  twice  at  four  and  a  half  to  six  feet  above,  once  at  ten  feet 
above,  and  in  one  case  there  were  no  less  than  twentv-five  to  thirtv 


1  Nacke.    Ueber  die  Darmperforation  ini  Typhus  Abdominalis,  Dissertation,  Wurzburg, 
1893. 

*  Hoffmann.    Untersuch.  und  der  path.  Anat.  Verand.  d.  Organe  beim  Abd.  Tji^hus.  1S69. 


144  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

perforations  in  the  jejunum.  In  167  cases  collected  by  Fitz,  the 
perforation  occurred  in  the  ileum  in  136  instances  ((S1.4  per  cent.), 
in  the  large  intestine  in  20  (12.9  per  cent.),  in  the  vermiform  appen- 
dix in  .3  cases,  in  ^Meckel's  diviM-ticulum  in  4,  and  in  the  jejunum  in 
2.  In  19  cases  there  were  two  perforations,  in  3  five  perforations, 
and  in  4  four.    Another  case  with  multiple  orifices  has  been  cited, 

A  very  extraordinary  case  is  that  reported  by  Heagler.^  A 
woman  suffering  from  ventral  hernia  was  attacked  with  typhoid 
fever,  and  perforation  of  the  ileum  occurred  in  the  hernial  sac. 
This  resulted  in  sloughing,  and  a  fecal  fistula  of  large  size  was 
formed.    Great  emaciation  ensued,  hut  the  w^oman  recovered. 

An  interesting  case  of  typhoid  fever  with  secondary  lesions 
involving  the  left  half  of  the  scrotum  has  been  reported  by  Spencer.- 
The  patient  was  thought  to  be  suffering  from  influenza;  and  had 
suffered  from  a  hernia  in  the  left  inguinal  region  for  nine  years. 
\Vlien  first  seen  at  the  hospital  the  left  half  of  the  scrotum  was 
greatly  swollen  and  distended,  the  skin  being  oedematous;  the 
swollen  area  was  tympanitic  on  percussion,  opaque  to  light,  and 
fluctuated,  and  at  the  inguipal  region  there  was  a  firm  mass  to 
which  an  impulse  was  transmitted  on  coughing.  An  incision  was 
made  from  which  pus,  gas,  and  sloughing  omentum  came  away. 
The  patient  died  seventeen  days  later,  and  the  postmortem  revealed 
the  fact  that  the  condition  of  the  scrotum  had  been  due  to  the  per- 
foration of  a  typhoid  ulcer. 

In  children  this  accident  is  very  much  more  rare  than  it  is  in 
adults.  J.  Lewis  Smith  states  that  it  is  met  with  only  once  in  232 
cases.  Wolberg  found  no  such  accident  in  277  cases  of  the  disease 
in  children  at  Warsaw.  Fitz  gives  the  following  table  as  to  age 
incidence : 

Age  at  which  Perforation  Occurs. 

1  to   10  years 7=3.6   per  cent. 

10  "   20  "  46  =  23.8 

20  "    30  "  77  =  39.8 

30  "   40  '•  45  =  23.3 

40  "    50  '•  14  =  7.2 

50  "    60  ••  2  =  1.0 

60  '•   70  "  1  =  0.5 

1  Heagler.    Correspondenzblatt  fiir  Schweizer  Aerzte,  1896,  No.  17. 
-  Spencer.    London  Lancet,  April  10,  1897. 


THE  AIJM/'JNTA/iV   CANAL   IN    Till':  DhlV ELOI'HI)  STAfJI'J      H5 

Jii  lliis  coiincclion  (lie  jiccoiiiil,  ^^ivcn  iriuiiy  years  ago  l>y  Tii njjin' 
of  iiitcstiiijil  perforation  in  cliildren  is  of  great  interest.  lie  tells  u.s 
that  he  saw  two  such  cases,  and  that  four  such  were  reported  in 
1834,  1835,  and  1838  by  Ilusson  and  Barrier.  Thr(;e  of  these  were 
gravely  ill,  and  when  perforation  occurred  they  j)assed  inlo  ffillapse 
and  died.  In  tli(!  two  Tiiupin  saw  atrocious  pain  (Jevelojjcd  in  the 
right  flank  and  collapse  ensued.  Death  occurred  in  thirty-six  hours, 
with  all  the  signs  of  peritonitis. 

Elsherg-  was  able  to  find  the  reports  of  25  operations  for  perfora- 
tion of  the  intestine  during  typhoid  fever  in  children  under  fifteen 
years  of  age.  Patterson^  has  collected  68  additional  cases  with  a 
mortality  rate  of  45.58  per  cent.  Griffith^  has  reported  six  instances 
of  this  complication  in  children,  and  is  of  the  opinion  that  the  com- 
plication exists  much  more  frequently  than  is  generally  believed. 
Paton^  reported  an  operation  for  perforation  in  a  child,  aged  seven 
years,  with  subsequent  recovery  of  the  patient,  while  Schofield's 
patient"  was  but  twenty  months  old.  Altogether  there  have  been 
reported  in  the  literature  over  100  instances  of  perforation  of  the 
bowel  in  children  during  typhoid  fever.  The  greater  number  of 
these  reports  have  been  published  during  the  last  ten  years,  during 
which  time  the  profession  have  had  their  attention  directed  to  the 
prevalence  of  typhoid  fever  in  children. 

To  one  unacquainted  with  the  subject  it  would  seem  that  there 
could  be  no  question  as  to  the  danger  of  death  from  perforation, 
in  1891  Reeves  stated  that  he  had  seen  five  cases  presenting  all 
the  signs  of  perforation,  and  yet  the  patients  recovered.  At  the 
same  meeting  Loomis  said  he  had  never  seen  recoverv  after  the 
presence  of  unmistakable  signs  of  perforation.  The  latter  view 
was  that  held  by  most  of  the  earlier  WTiters;  but  Buhl,  in  1857, 
recorded  a  case  in  which  death  did  not  succeed  perforation  for 
forty-five  days,  and  then  as  the  result  of  hemorrhage  from  a 
mesenteric  artery.     The  autopsy  showed  that  a  perforation  had 

1  Taupin.    Journal  des  Connaissances  Med.  Chi.,  1839. 

2  Elsberg.    Quoted  by  Patterson  in  American  Journal  of  Medical  Sciences,  May,  1909 
'Patterson.     American  Journal  of  the  Medical  Sciences,  May,  1909. 

*  Griffith.    Philadelphia  Medical  Journal,  February  25,  1905. 

*  Paton.     British  Medical  Journal,  February  25,  1905, 
«  Schofield.     British  Medical  Journal,  May  24,  1906. 

10 


146  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

occ'urretl.  l>iit  had  been  closed.  Murchison  states  that  rare  cases 
are  met  a\  ith  in  which  recovery  takes  phice.  At  the  present  time 
it  is  a  well-recognized  fact  that  cases  may  recover,  but  that,  as 
]\Iurchison.  says,  they  are  rare,  unless  surgical  aid  is  given  the 
patient  very  sot)n  after  the  accident.     (See  operative  interference.) 

Perforation  does  not  always  produce  death,  because  it  may 
not  cause  anything  more  than  a  very  localized  abscess,  owing  to 
a  protective  peritonitis  which  walls  off  the  general  cavity  from 
infection.  Eisner^  reports  such  cases,  and  Pearson^  records  a  case 
in  which  during  relapse  an  ileocsecal  abscess  formed,  the  pus  having 
a  fecal  odor.  In  another  case^  a  man  had  a  perityphlitis  on  the 
twentv-eighth  day,  and  passed  two  ounces  of  pus  by  the  rectum 
on  the  fiftieth  day.  Keen  records  a  case  in  which  an  abscess  formed 
in  the  right  side,  which  opened  into  the  ascending  colon,  and  finally 
a  fecal  fistula  developed.  He  also  records  a  case  sent  him  by  Dr. 
Schureraen,  of  Tom's  River,  N.  J.,  of  an  abscess  which  opened  near 
the  anus,  giving  vent  to  a  great  deal  of  pus,  in  the  third  week  of  the 
disease.  Later,  another  opening  formed.  jMajor*  records  a  case 
in  which  collapse  occurred  on  the  eighteenth  day  of  the  disease,  and 
three  weeks  later  an  abscess  biu-st  into  the  rectum,  and  the  patient 
recovered. 

Low's^  case  had  symptoms  of  perforation  in  the  third  week,  and 
peritonitis.  Later,  an  abscess  burst  through  the  abdominal  wall, 
but  the  patient  recovered.  Again,  in  Lehman's  case  perforation 
occurred  at  the  end  of  the  third  week,  and  death  occurred  a  month 
later.  Li  the  abdominal  pus  the  bacillus  of  Eberth  was  found. 
Schmidt"  has  recorded  a  case  of  pyopneumothorax  subphrenicus, 
from  which  three  quarts  of  pus  containing  a  pure  culture  of  the 
bacillus  of  Eberth  was  obtained. 

That  death  does  not  always  follow  rapidly  after  perforation  of 
the  bowel  in  typhoid  fever  is  also  proved  by  a  case  reported  by 
O'Carroll,^  in  which  perforation  of  the  intestine  occurred  on  the 

1  Eisner.    Transactions  of  tlie  Medical  Society  of  the  State  of  New  York,  1892,  314 

2  Pearson.    British  Medical  Journal,  1891,  i,  861. 

3  Adam.     Australian  Medical  ,Journal,  1887,  ix,  182. 

*  Major.     British  Medical  .lournal,  1891.  i.  18.  ^  Low.     Ibid.,  1881,  ii,  122 

8  Schmidt.    Deutsche  medicinische  Wochenschrift,  1896,  No.  32. 
'  O'Carroll.    British  Medical  Journal,  February  13,  1893. 


Till':  ALIMENTAUY   CANAL    IN    Till':   ni:\  i:I/)I'I:Ij   STACI:      147 

thirty-sixth  diiy,  uiid  llic  paliciit  (Ji(J  not  die  unlil  ihc  hl'tj-iiintli 
day,  when  an  adhesive;  peritonitis  was  found,  ;ind  ;in  ahsees.s  wliieh 
had  been  walled  ofl"  I'roni  (he  rest  of  the  p(;ritonc-nrn.  All  of  iIk; 
intestinal  nlcers  except  the  one  which  had  fx'rfonifcd  had  hc;dc(J. 

Without  douht  Jiiatiy  of  the  cases  of  so-called  perforation  wliic}i 
have  l)een  reported  as  endin^-  f;ivoral)Iy  have  been  eases  in  which 
tiiere  was  no  j)erl'oration,  and  only  a  mf)re  or  less  severe  loeali/efl 
peritonitis.  The  symptoms  of  tliis  condition  may  be  so  precisely 
those  of  perforation,  that  an  autopsy  or  exploratory  incision  may 
be  needed  to  differentiate  them,  and  peritonitis  may  arise  from  so 
many  intra-alidominal  lesions  that  its  presence  from  these  causes 
nnist  always  be  suspected. 

Cases  of  recovery  from  perforation,  without  surgical  aid,  are, 
however,  so  rare  as  to  be  regarded  as  curiosities. 

The  prognostic  and  therapeutic  view  of  cases  of  perforation  are 
well  expressed  by  the  following  quotations  from  Gairdner,  Fitz, 
Keen,  and  others: 

Gairdner^  says:  "What,  then,  is  the  proportion  of  cases  which 
recover  without  surgical  interference  when  symptoms  of  general 
peritonitis  have  set  in? 

"It  is  difficult  to  estimate  the  proportion  numerically,  but  such 
recoveries  are  certainly  exceedingly  rare.  Thus,  Todd  and 
Jenner,^  in  a  long  life  of  large  experience,  saw  one  case  each; 
Tweedie,  2;  Murchison  carefully  collected  six  cases,  but  only  two 
were  his  own. 

"A  fair  number  of  cases  may  be  found  in  medical  literature, 
reported  with  more  or  less  accuracy,  but  it  is  seldom  that  an  indi- 
vidual experience  includes  more  than  one  case,  while  many  of  large 
experience  have  seen  no  such  cases,  and  even  doubt  the  possibility 
of  recovery  after  perforation  of  the  intestine  freely  into  the  peritoneal 
cavity.  Now,  Murchison,  at  p.  524  of  the  secojid  edition  of  his 
work  on  continued  fevers,  states  that  in  ten  years,  between  the  pub- 
lication of  the  first  and  second  editions  of  that  work,  he  had  attended 
'more  than  two  thousand  cases'  of  enteric  fever;  certainly,  he  must 

'  Gairdner.    Glasgow  Medical  Journal,  vol.  xlvii,  p.  100. 

-  Todd  and  Jenner.    Collected  Essays  and  Lectures  on  Fevers,  pp.  311  and4S4,  London, 
Rivington,  Percival  &  Co.,  1893. 


148  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

have  attended  even  more  before  the  puhlicatioii  of  the  lirst  edition; 
so  tliat  his  personal  experience  ii|)  (o  tliat  time  may  fairly  be  put 
down  as  at  least  five  thousand.  In  another  place  he  estimates  the 
occurrence  of  perforation  of  the  intestii^e  in  his  cases  at  a  fraction 
over  3  per  cent.,  so  that  in  about  150  of  these  cases  that  accident 
must  have  occurred.    Two  only,  as  we  have  seen,  recovered. 

"If,  then,  the  number  of  unsuccessful  laparotomies  published  be 
trebled,  so  as  to  make  sure  of  including  those  unpublished,  roughly 
this  gives  fifty-four  unsuccessful  cases  and  five  successful  cases. 

"^^htn  it  is  remembered  that  little  selection  has  been  made  in 
the  cases  operated  on  (Van  Hook's  dictum  is,  'the  only  contra- 
indication is  a  moribund  condition  of  the  patient'),  it  may  be  claimed 
that  the  'prentice  hand'  of  surgery  has  considerably  improved  on 
the  very  best  treatment  by  other  means." 

On   the  other  hand   Fitz   says:   "It   appears 

that  of  27  cases  of  peritonitis  in   typhoid  fever,  wdiatever  may 

have  been   the  cause though  often  attributed  to 

intestinal  perforation,  3  recovered  after  operation,  17  after  resolu- 
tion, and  9  after  the  spontaneous  discharge  of  the  pus.  The  com- 
parison of  this  series  of  cases  with  those  showing  the  results  of 
early  laparotomy  for  symptoms  suggesting  typhoid  perforation, 
indicates  that  the  appropriate  treatment  for  this  complication 
would  be  delay  until  a  probable  encapsulated  exudation  proved 
unduly  slow  in  absorption.  An  immediate  or  early  laparotomy 
for  the  relief  of  the  peritonitis  seems  advisable  only  when  the 
patient's  condition  is  exceptionally  good.  Should  the  signs  of 
the  exudation  persist  for  a  week  or  more,  and  the  general  con- 
dition of  the  patient  permit  an  incision,  surgical  treatment  would 
then  be  strongly  advisable.  That  the  patient  may  live  for  weeks 
after  perforation  has  taken  place  is  illustrated  by  the  cases  of 
Buhl  and  Hofimann  already  mentioned. 

"In  brief,  immediate  laparotomy  for  the  relief  of  suspected 
intestinal  perforation  in  typhoid  fever  is  only  advised  in  the  milder 
casts  of  this  disease.  In  all  others,  evidence  of  a  circumscribed 
peritonitis  is  to  be  awaited,  and  may  be  expected  in  the  course  of  a 
few  days.  Surgical  relief  to  this  condition  should  then  be  urged  as 
soon  as  the  strength  of  the  patient  will  warrant." 


THE  ALIMENTARY   CANAE   IN    THE  DEVELOI'EI)  STACE      MQ 

We  <l()  nol.  believe  (liiil.  V\lv.  lioMs  llicse  view.s  lodjiy.  Wc 
certainly  do  not.  ](;U,lier  we  nffrvv.  with  Keen  wlien  he  says: 
"Wlieri  once  f)liy.sicians  an;  not,  only  on  I  lie  ;ilert  to  oh.servc 
the  symptoms  of  perioral  ion,  hul  when  ihe  knowled^a-  lh;it  fjer- 
foration  of  tlie  bowel  can  be  remedied  by  surgical  means,  has 
permeated  the  profession,  so  that  the  instant  that  perforation  takes 
place  the  surgeon  will  be  called  upon,  and,  if  the  case  be  suitable, 
will  operate,  we  shall  find  unquestionably  a  niueh  hi rger  percentage 
of  cures  tlian  have  tiius  far  been  re})orted.  But  even  at  present  we 
have  a  reasonably  large  number  from  which  to  draw^  eone-lusions. 
In  the  table  appended  to  this  chapter,  Dr.  Westeott  has  collected 
83  well-authenticated  cases.  This  gives,  as  a  general  result,  16 
recoveries,  or  19.3G  per  cent,  of  cures  and  80.64  per  cent,  of  deaths. 
When  this  is  contrasted  with  Murchison's  unchallenged  figures  of 
90  to  95  per  cent,  of  deaths  after  perforation  without  operation, 
we  may  well  take  courage  for  the  future." 

Since  Keen's  essay,  Zesus^  has  collected  from  the  literature  255 
cases  of  laparotomy  for  perforation  in  typhoid  fever,  with  95 
recoveries.  He  found  that  in  67  of  the  patients  who  were  operated 
upon  within  twenty-four  hours  after  the  symptoms  of  perforation 
were  observed,  recovery  occurred  in  30,  while  in  23  in  which  opera- 
tion was  further  delayed  only  3  recovered. 

Harte^  found  in  his  analysis  of  nearly  600  cases  that  24.65  per 
cent,  left  the  surgeon's  hands  well,  there  being  a  mortality  of  75.35 
per  cent.  We  feel,  with  Harte,  that  this  recovery  rate  is  too  high, 
because  of  the  tendency  to  report  only  the  successful  results. 
Harte  also  reported  80  cases  operated  upon  at  the  Pennsylvania 
Hospital  for  typhoid  perforation,  of  which  15  recovered,  giving  a 
mortality  of  81.25  per  cent.  Vaughan^  has  recently  reported  ten 
instances  of  this  complication  operated  upon  by  him,  with  a  recovery 
rate  of  40  per  cent.  Cobb^  reports  30  per  cent,  of  recoveries  in  a 
series  of  20  patients  who  developed  perforation  during  t}-phoid 
fever  in  the  Massachusetts  General  Hospital. 


1  Zesus.    Wien.  klin.  AVochen.,  190-i. 

2  Harte.     Boston  Medical  and  Surgical  Journal,  July  18,  1907. 
'  Vaughan.  Washington  Medical  Annals,  March.  1906. 

*  Cobb.     Boston  Medical  and  Surgical  Journal,  July  IS,  1907. 


150  WELL-DKYKLOPED  STAGE  OF  THE  DISEASE 

Patterson^  has,  since  their  report,  collected  369  additional  cases, 
with  242  deaths,  or  a  mortality  rate  of  65.58  per  cent. 

Our  own  tVelinn-  in  this  matter  is  well  summed  up  in  the  words 
of  Mikuiic/,-  who  said  at  INIagdeburi;-,  as  jouo-  nv^o  as  1884:  "If 
suspicious  of  a  perforation,  one  should  not  wait  for  an  exact  diag- 
nosis and  for  peritonitis  to  develop  to  reach  a  pronounced  degree, 
but,  on  the  contrary,  one  should  immediately  proceed  to  an  explora- 
tory operation,  which  in  any  case  is  free  from  danger."  Again, 
Cushing^says:  "When  the  diagnosis  is  made,  operation  is  indicated 
whatever  the  condition  of  the  patient.  As  Al)l)e's  case  excmpliHes, 
no  case  may  be  too  grave.  A  precocious  exploration  from  an  error 
in  diagnosis  is  not  followed  by  untoward  consequences,  such  as  must 
invariably  be  expected  after  a  neglected  and  tardy  one." 

In  common  with  others,  we  were  at  one  time  of  the  opinion  that, 
in  cases  of  sudden  onset  followed  by  collapse,  the  patient  should 
be  given  sufficient  time  to  rally  before  the  oj)eration  was  performed. 
We  are  now  convinced  that  less  danger  is  to  be  anticipated  from 
immediate  operation  than  would  result  by  delay.  It  will  be  a  step 
forward  and  will  result  in  bringing  about  a  lower  death  rate  in 
these  cases,  when,  as  suggested  by  Harte,  the  management  of 
hospitals  will  insist  that  when  the  patient  is  admitted  to  the  medi- 
cal ward  the  physician  in  charge  shall  have  the  consent  of  the 
patient  and  his  friends  for  an  immediate  operation  should  urgent 
conditions  arise. 

W^hen  the  first  edition  of  this  essay  was  published,  ten  years  ago, 
there  were  many  physicians  and  not  a  few  surgeons  who  were  by 
no  means  convinced  that  operation  for  perforation  of  the  intestine 
was  justified  and  who  w'ere  inclined  to  regard  the  performance  of 
such  an  operation  in  the  light  of  a  "preliminary  autopsy."  In  the 
ten  years  that  have  passed  much  advance  has  been  made  in  surgical 
technique,  and,  more  important  still,  physicians  have  learned  that 
to  insure  success  in  such  operations  the  surgeon  must  be  given  an 
opportimity  of  operating  as  soon  as  the  diagnosis  of  perforation 
can  be  made. 


'  Patterson.  American  Journal  of  the  Medical  Sciences,  May,  1909. 
-  Mikulicz.  Quoted  by  Thayer  in  ProKre.s.sive  Medicine,  1899,  vol.  i. 
5  Gushing.    Johns  Hopkins  Hosjjifal  Bulletin,  1898,  ix,  257. 


THE  AfJM/'JNTAUV   CANAL   IN    Till-:    DIA' l:l/)l' i:i)  STACI-:      1^1 

Thill  ciirlicr  opci'jilioii.s  ;irc  rcsj^onsiMc  Foe  I  lie  iii;irk((|  decrease 
in  inorl.ilily  can  be  seen  wlicii  we  coiiij);!!-*-  (lie  .success  of  the  sur- 
geon today  ii)  dealing  with  ty[)}ioid  perforation  witli  tiie  fieavy 
mortality  rate  of  ten  years  ago. 

In  addition  to  the  signs  or  symj)toms  of  [)erf oration  already 
mentioned  there  are  several  additional  j)oirits  to  be  considered. 
Among  the  foremost  in  importance  is  the  demonstration  of  gas  in 
the  peritoneal  cavity,  so  that  the  liver  is  pushed  away  froui  the 
abdominal  wall  in  such  a  manner  tiiat  the  ordinary  area  of  liver 
dulness  largely  disappears.  Percussion  of  tlie  right  hypochon- 
drium  is,  therefore,  an  essential  procedure  in  the  physical  diagnosis 
of  these  cases.  The  only  fallacy  underlying  this  test  is  the  possi- 
bility of  a  portion  of  the  colon,  when  greatly  distended  with  gas, 
obscuring  liver  dulness.  It  is  to  be  remembered,  however,  that  a 
very  large  number  of  cases  fail  to  develop  distention  until  the 
patient  is  nearly  moribund,  and  so,  while  the  discovery  of  such 
physical  signs  is  of  value  in  reaching  diagnosis,  inability  to  do  so 
does  not  prove  that  perforation  has  not  occurred,  but  this  is  a  rare 
occurrence.  The  finding  of  a  distinct  leukocytosis  is  of  value 
as  indicative  of  perforation,  but  it  is  by  no  means  positively  diag- 
nostic. 

There  is  a  precaution  to  be  taken  in  cases  of  suspected  per- 
foration which  must  not  be  overlooked,  namely,  that  peritonitis 
may  develop  from  extension  of  the  inflammatory  process  in  the 
bowel  or  by  reason  of  the  migration  of  microorganisms  through 
those  parts  of  the  bowel  wall  which  have  been  impaired  by  the 
ulcerative  process.  In  such  cases  the  pain,  swelling,  and  dia- 
phragmatic paralysis  may  all  be  present  without  being  due  to 
perforation,  and  so  closely  may  the  symptoms  of  perforation  be 
aped  that  operation  has  been  performed,  with  the  discovery  that 
no  perforation  had  occurred;  thus,  in  a  case  under  the  care  of 
Herringham,  nothing  was  found  at  the  section  and  the  patient 
recovered.  Perforation  may  also  be  simulated  by  rupture  of  the 
peritoneum  over  a  swollen  mesenteric  gland. 

Scudder^  has  pointed  out  the  difficulties  of  diagnosis  in  abdominal 
complications  during  typhoid  fever  in  an  interesting  paper  upon 

1  Scudder.     Boston  Medical  and  Surgical  Journal,  July  18.  1907. 


152  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

"The  jNIistaken  Diagnosis  of  Typhoid  Perforation."  He  divides 
the  errors  of  diaonosis  into  three  groups:  (1)  Those  in  which  no 
lesion  is  thscoverahle;  (2)  those  in  which  the  lesion  found  tloes  not 
involve  the  peritoneum;  and  (3)  those  in  which  the  lesion  found 
involves  the  peritoneum. 

In  the  first  class  are  the  cases  in  which,  although  all  the  signs  of 
perforation  are  present,  no  lesion  can  be  demonstrated  at  operation, 
and  recovery  follows.  Instances  of  this  kind  have  been  reported  by 
Herrineham  and  Bowlbv ,'  Shattuck,  "Warren-  and  Co])l),  Scott,' 
Le  Conte,  and  others.  To  the  second  group  belong  those  instances 
of  intercurrent  disease  the  symptoms  of  which  simulate  those  of 
perforation.  Examples  of  these  are  found  in  certain  cases  of 
pneumonia,  pleuritis,  gastritis,  and  enterocolitis.  Intestinal 
hemorrhage,  Zenker's  degeneration  of  the  abdominal  muscles,  often 
beginning  w-ith  hemorrhage  into  the  muscle,  and  distention  of 
the  urinary  bladder  cause  symptoms  simulating  peritonitis  due  to 
perforation.  Other  causes  of  peritonitis  are  necrosis  of  the  mesen- 
teric glands,  infarction  of  the  spleen,  rupture  of  the  spleen,  abscess 
in  the  wall  of  the  bladder,  ovarian  and  tubal  abscesses,  and  abscess 
of  the  liver.  In  addition  to  these,  acute  intestinal  obstruction,  acute 
intussusception,  volvulus,  iliac  or  mesenteric  thrombosis,  and  infre- 
quently such  complications  as  orchitis,  with  probable  thrombosis 
of  the  mesenteric  arteries,  fecal  impaction,  and  strangulation,  with 
rotation  of  Meckel's  diverticulum,  may  occur. 

Liver  and  Gall-bladder  and  Appendix. — The  frequency 
with  which  complications  involving  the  liver,  gall-bladder,  and 
vermiform  appendix  arise  render  it  necessary  that  these  be  con- 
sidered more  at  length. 

Ten  years  ago  we  wrote  that  very  rarely  peritonitis  arises  from 
cholecystitis,  with  or  without  gallstones,  but  Liebermeister  has 
recorded  two  cases  in  which  rupture  of  the  gall-bladder  with  escape 
of  gallstones  into  the  abdominal  cavity  took  place. ^ 

During  the  past  ten  years  the  surgical  treatment  of  the  gall-bladder 
complications  of  typhoid  fever  has  made  great  progress,  but  the 

•  Herringham  and  Bowlby.     Britisli  Medical  Journal,  1897. 

2  Warren.     Boston  Medical  and  .Surgical  Journal,  June  28,  1900. 

^  Scott.    University  of  Pennsylvania  Medical  Bulletin,  January  9,  1905. 

*  Boston  Med.  and  Surg.  Jour.,  July  18,  1907. 


TlIK  AfJMMNTAIiY   CAIVAL  IN    I'll  I'!    DHV  r:i/)l'i:i)  STAdH      15.'^ 

surgeon  is  nol,  inorc  iiilcrc.slcd  Iti  llii.s  grciil,  qui  stioii  tlinii  is  flic 
pliy,si(;i!iii,  bcciuisc!  the  rc.sjxjii.sihility  for  diiigrifj.sis  iind  (lie  iillirnuU; 
treatment  of  the  case  both  from  the  medical  and  surgical  standpoint 
in  most  instances  rests  upon  the  latter.  The  surgical  complications 
involving  the  gall-l)ladder  are  second  only  in  importance  to  those  of 
perforation  of  the  intestine.  As  the  truth,  as  to  the  comparative 
frequency  of  empyema  of  the  gall-bladder,  followed  by  rupture  and 
general  peritonitis,  becomes  known,  the  profession  are  awakening  to 
the  fact  that  prompt  surgical  intervention  is  more  important  in  the 
presence  of  this  disaster  than  it  is  in  intestinal  perforation.  In  the 
latter  condition  there  have  been  a  few  authentic  recoveries  following 
perforation  without  operation,  but  in  those  cases  in  which  rupture 
of  the  gall-bladder  has  occurred  and  in  which  no  operation  has 
been  performed,  death  has  followed  in  every  instance.  It  is  well 
for  all  physicians  to  bear  in  mind  that  it  is  much  safer  to  submit  a 
patient  to  the  danger  of  a  laparotomy  for  the  purpose  of  draining 
a  distended  gall-bladder  than  to  wait  until  perforation  makes  an 
operation  unavoidable. 

That  a  patient  who  has  cholecystitis  without  perforation  may 
recover  without  the  aid  of  the  knife  is  true,  but  that  such  a  patient 
is  in  great  danger  of  perforation  during  the  time  the  gall-bladder  is 
distended  is  equally  true.  It  is  also  well  to  bear  in  mind  that 
although  a  patient  may  recover  from  the  cholecystitis  "v\ith  empyema 
of  the  gall-bladder  this  patient  is  always  in  danger  of  a  recur- 
rence of  this  condition.  Because  of  these  well-recognized  facts  no 
physician  can  fail  to  blame  himself  if  through  his  delay  in  availing 
himself  of  the  advantage  of  the  assistance  of  a  surgeon  his  patient 
is  deprived  of  his  best  chance  for  life  and  future  health. 

Appendicitis. — The  relation  of  t^^hoid  fever  to  appendicitis  is 
one  of  great  interest.  It  has  been  thought  by  some  that  appendicitis 
arising  in  typhoid  fever  was  a  mere  coincidence;  by  others,  that  its 
origin  depended  upon  a  general  infectious  process,  and,  again,  by 
others,  that  it  was  due  to  the  direct  infection  with  the  bacillus  of 
Eberth.  Probably  all  these  views  hold  true  in  individual  cases.  The 
richness  of  the  appendix  in  lymphoid  tissue,,  and  the  fact  that  typhoid 
fever  is  particularly  prone  to  attack  such  tissues,  renders  this  organ 
peculiarly  susceptible  on  theoretical  grounds.     That  this  view  is 


154  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

correct  is  proved  l)y  tlu'  research  of  Hopfenhausen/  who  preserved 
the  aj^peiKhces  obtained  from  thirty  cases  of  typhoid  fever  and 
studied  them  under  Stilhng  in  the  University  of  I^ausanne.  She 
concludes  that  moderate  changes  in  the  appendix  may  be  found  in 
nearly  all  cases  of  this  character,  that  they  are  most  marked  in 
the  earlier  stage  of  the  malady,  and  consist  chiefly  in  cellular 
iiiHltration.  s])ecific  lesions  l)eing  rare  and  not  being  sufHcicnt  to 
produce  the  more  severe  forms  of  appendicular  disease.  So  much 
difference  of  opinion  has  existed  concerning  this  complication  that 
it  would  seem  wise  to  classify  the  cases  into  four  groups: 

1.  A  group  in  which,  because  of  the  severe  and  localizing  intes- 
tinal symptoms,  early  in  the  typhoid  illness,  a  diagnosis  of  appen- 
dicitis is  made. 

2.  A  group  in  which  a  true  attack  of  appendicitis  occurs  during 
the  course  of  typhoid  fever,  such  attacks  being  regarded  simply 
as  coincidences. 

3.  A  group  in  which  the  attack  of  appendicitis  is  the  result  of 
the  specific  inflammation  occurring  in  the  lymphoid  tissues  of  the 
appendix. 

4.  A  group  appearing  during  convalescence  or  even  later,  in 
which  there  seems  reason  to  believe  that  a  direct  or  indirect  rela- 
tionship exists  between  the  two  conditions. 

True  appendicitis  complicating  typhoid,  in  the  sense  of  inflam- 
mation of  this  part  severe  enough  to  produce  abscess,  is  undoubtedly 
not  a  very  rare  affection.  One  such  case  is  reported  farther  on, 
as  occurring  in  the  practice  of  one  of  us  (Hare).  Here  a  large 
abscess  containing  over  a  pint  of  pus,  having  the  odor  of  a  typhoid 
fever  stool,  was  allowed  to  escape  by  an  incision.  Recovery 
occurred.  In  more  frequent  instances  the  appendix  is  the  seat 
of  typhoid  ulcer,  although  the  recorded  cases  in  which  this 
lesion  has  been  found  are  surprisingly  few.  This  scantiness  of 
reports  is  probably  due  in  large  part  to  the  fact  that  the  appendix 
is  not  carefully  examined  for  lesions  in  making  autopsies,  for  in  the 
cases  with  which  we  are  acquainted  in  which  the  appendix  has  been 
carefully  examined,  appendicular  lesions  have  been  surprisingly 
frequent.    At  a  meeting  of  the  Pathological  Society  of  Philadelphia 

1  Hopfenhausen.    Revue  M(*d.  de  la  Suisse  Romande,  February  20,  1899. 


THE  ALIMENTARY   CANAL  IN    Till':    hh'.V l-:i,()l'l':i)  STACI-:      jT,.'; 

ten  yciU'S  <i^o,  Slciij^cl  iiuhIc  ;i  \crl);il  icporl  of  .sc\cr';ii  iii^l;ii)fc:s  in 
which  tyj)hoi(l  ulcer  luul  been  lonnd  in  the  iij)j>en(lix,  as  flid  also 
Sailer,  and  in  a  pa[)er  on  typhoid  ulcer  (;i'  the  (jesophagus,  Uie.srnan 
incidentally  mentioned  apj)CMdi(  iihir  typhoid  ulcer  as  being  also 
present  in  his  case. 

Keen  has  well  said,  therefore,  in  his  essay,  that  in  all  cases  of 
operation  for  inlesfinal  perforation  in  typhoid  fever  the  surgeon 
should  examine  the  appendix  to  discover  if  it  is  diseased.  In  Keen's 
table  of  operations  done  for  intestinal  perforation,  cases  of  asso- 
ciated appendicular  lesions  are  recorded  by  Bontecou,'  Kimura,^ 
and  AlexandrofP  (there  were  three  large  perforations  of  the  appen- 
dix in  this  case). 

Although  the  subject  of  appendicitis  complicating  tyj)hoid  fever 
had  been  discussed  previously,  the  greater  number  of  the  contri- 
butions upon  this  subject  have  been  published  since  1900.  Scott,* 
in  his  study  of  9713  cases  of  typhoid  fever  at  the  Pennsylvania 
Hospital,  found  that  in  this  series  there  occurred  382  cases  of  per- 
foration, in  17  of  which,  or  4.4  per  cent.,  the  appendix  was  the  only 
site  of  perforation,  while  16  per  cent,  of  the  cases  diagnosticated 
perforation  was  in  reality  due  to  diseased  appendices,  and  in  5  cases 
there  were  found  typhoid  ulcers  in  the  appendix.  Ashhurst"  was 
able  to  find  82  instances  of  lesions  in  the  appendix,  while  in  the 
series  of  83  cases  studied  at  autopsy  by  Baer,^  he  found  5  lesions  in 
the  appendix.  Deaver,^  Franjois,^  Frazier  and  Thomas,®  Hopfen- 
hausen/°  Rolleston,"  Patterson, ^^  and  others  have  written  of  the 
appendicular  complications  of  typhoid  fever,  and  Deaver  was  able 
to  collect  40  cases  of  perforation  of  this  organ  during  typhoid  fever 
and  41  cases  in  which  the  organ  was  inflamed.     Of  the  40  cases 

1  Bontecou.    Journal  of  American  Medical  Association,  January  28,  188S,  p.  106. 

2  Kimura.    Sei-i-kwai  Medical  Journal,  1890,  ix,  55. 

3  Alexandroff.     Report  of  Hospital  St.  Olga,  in  Moscow,  1890,  p.  198. 

■•  Scott.     University  of  Pennsylvania  Medical  Magazine,  .January  9.  1905. 
'  Ashhurst.     American  Journal  of  the  Medical  Sciences,  April,  1908. 
6  Baer.    Ibid.,  May,  1904. 

^  Deaver.    Appendicitis,  etc.,  Philadelphia,  1905. 

s  Francois.    L'appendicite  au  cours  de  la  fie\Te  tj-phoide,  Paris,  1904. 
^  Frazier  and  Thomas.     Universitj-  of  Pennsylvania  Jledical  Bulletin,  July  and  August, 
1907. 

10  Hopfenhausen.    Rev.  Med.  de  la  Suisse  Romande,  1899,  19, 105. 

11  Rolleston.    Lancet,  May  29,  1898. 

1-  Patterson.    American  Journal  of  the  Medical  Sciences,  Mav.  1909. 


156  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

which  perforated,  7  were  operated  upon,  with  4  deatlis;  the  remain- 
ing 33  cases  all  died.  Thirty  of  Deaver's  41  cases  which  showed 
inflammation  of  the  appendix  were  subjected  to  operation,  with  4 
deaths;  of  the  10  cases  not  operated  upon,  9  died.  Patterson  was 
able  to  collect  15  cases  of  perforation  of  the  appendix  in  addition  to 
the  40  cases  collected  by  Deaver.  All  were  operated  upon,  with  4 
deaths — a  mortality  of  33.33  per  cent.  Patterson  also  collected 
22  additional  cases  of  appendicular  inflammation,  all  of  which 
cases  were  operated  upon,  with  4  deaths — a  mortality  rate  of 
18.18  per  cent. 

Additional  cases  have  been  chiefly  collected  by  Kelynack,^  who 
points  out  that  INIurchison^  saw  2  cases  of  appendicular  ulcera- 
tion, one  in  a  girl,  aged  thirteen  years,  four  ulcers  being  present. 
Two  small  perforations  were  found  in  it.  Norman  Moore^  records 
4  cases.  Death  was  due  in  2  of  them  to  perforation  of  the 
appendix;  another  had  an  ulcer  at  the  tip  of  the  organ.  Fitz  found 
in  257  cases  of  appendicular  perforation  only  3  due  to  typhoid 
fever,  and  in  a  later  paper,^  in  167  cases,  5  instances  with  this 
lesion.  The  reports  of  Morin^  and  Heschl"  give  a  much  hgher 
percentage.  Thus,  Morin,  in  67  collected  cases,  found  12  examples 
of  appendicular  perforation,  or  18.75  per  cent.,  and  Heschl,  in  56 
cases,  found  this  lesion  in  8,  or  14.3  per  cent.  McArdle^  has  also 
reported  a  case. 

On  the  other  hand,  perforation  in  this  part  is  more  apt  to  be 
followed  by  recovery  than  elsewhere,  and  this  may  explain  why  it 
is  that  the  best  postmortem  records  are  so  scant  in  this  respect. 
Fitz  asserts  that  the  more  closely  the  symptoms  of  perforation 
resemble  those  of  appendicitis  the  more  favorable  is  the  prognosis. 

Rolleston^  states  that  in  14  out  of  60  cases  of  enteric  fever  seen  at 
St.  George's  Hospital,  London,  changes  were  found  in  the  appendix. 

1  Kelynack.    Pathology  of  the  Vermiform  Appendix,  London,  1892. 

2  Murchison.     The   Continued   Fevers,    1873,  2d  ed.,   p.   623,   and  Trans.   Pathological 
Society,  London,  1866,  xvii,  127 

'  Moore.    Tran.s.  Pathological  Society,  London,  1883,  xxxiv,  113. 

*  Fitz.    Trans  Association  of  American  Physicians,  1891. 

'  Morin.    Thfese  de  Paris,  1869. 

8  Heschl.     Schmidt's  Jahrbucher,  1853,  Ixxx,  p.  42 

'  McArdle.    Trans.  Royal  Academy  of  Medicine,  Ireland,  1888,  vi,  392. 

8  Rolleston.    Lancet,  1898,  vol.  i,  p.  1401. 


77//';  AfJMJ<;NTAh',Y   C'ANAf.  IN    TIIH    DHV ICLOI'I'ID  i^TACE       jr>7 

In  T)  llicrc  w;is  (iiMicraclioii,  in  7  iil''cr;il  ion,  jind  m  '1  jj'iTociI  ion. 
Perforation  of  the  bowel  occuiicd  in  IS  of  llie.sc  (iO  cases — a  very 
high  j)crc('nta<(('. 

In  the  very  interesting  piijx-i-  hy  Ilopfenliiinscn'  on  tliis  (opic, 
already  quoted,  she  tells  us  that  she  eoliec^ted  sdilislics  conccining 
the  appendix  in  <SOS  cases  which  came  to  autopsy  in  St.  J'cters- 
burg,^  and  found  perforation  of  the  appendix  in  eight  cases.  In 
one  of  these  the  perforation  had  caused  perityphlitis,  found  post 
mortem;  in  two  others  the  diagnosis  was  made  in  hf<'.  In  117 
cases  general  peritonitis  was  foujid,  and  in  ]()0  this  was  Jittrihuted 
to  intestinal  perforation. 

In  all  probability  typhoid  fever  predisposes  a  patient  to  appen- 
dicitis. Keen  has  hinted  at  this  without  adducing  any  statistics 
to  prove  it,  and  cases  can  be  found  in  literature  which  point  to  it. 
In  the  cases  collected  by  Hopfenhausen,^  we  find  this  subject  also 
discussed.    She  found  the  following  statistics : 

No.  of 

cases  proceed-  No.  of 

ing  from  cases 
typhoid  fever.         observed. 

Hopital  cantonal  de  Lausanne 9  200 

Sonnenburg 6  130 

Pozzi 1  1 

Bull •.3  12 

Hecker 1  35 

Bossard 2  26 

Douneff 4  52 

Le  Guern        1  110 

Jacobson 2  6 

Schnellen 1  32 

Langheld 4  112 

Holin 1  2 

Jacob 2  25 

Total 37  743 

The  interval  between  the  two  diseases  in  these  cases  was  generally 
so  long  that  the  figures  disapprove  the  relationship  rather  than  prove 
it.  Thus  in  5  cases  it  followed  in  from  twenty-five  to  forty  years; 
in  24  from  ten  to  twenty  years;  in  2  cases  in  three  years;  in  1  in  two 

1  Hopfenhausen.  Revue  M^d.  de  la  Suisse  Romande,  February  20.  1899.  Etude  sur 
i'dtat  et  I'appendice  vermiforme  dans  le  cours  de  la  fi^vre  typhoide. 

">■  Protocoles  des  institute  pathologique  de  I'Hopital  Municipal  d'Obouchow  et  de  I'Hopital 
Municipal  de  Ste.  Marie-Madeleine,  1SS9-1S97. 

'  Hopfenliausen.    Revue  M(?dicale  de  la  Suisse  Romande,  February  20,  1S99. 


158  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

vears;  in  1  in  one  year;  in  3  from  three  to  .six  months;  in  1  during 
typhoid  fever. 

In  only  one  instance  was  the  appendicitis  near  enough  to  the 
attack  of  typhoid  fever  to  bear  the  true  relationship  of  cause  and 
effect,  namely,  that  of  Bossard,'  in  which  perityphlitis  followed  in 
the  same  month. 

The  senior  author  had  under  his  care  the  following  illustrative 
case  without  abscess:  A  boy,  aged  nine  years,  because  of  ill 
health,  was  taken  to  the  seashore,  witli  the  hope  that  it  would 
benefit  him.  During  the  first  week  at  Atlantic  City  he  suffered 
from  continued  fever,  ranging  from  102°  to  103°,  for  which 
no  adequate  cause  could  be  discovered.  His  fever  then  disap- 
peared suddenly,  and  was  absent  for  a  week,  during  which 
time  he  ate  heartily  and  seemed  to  improve  greatly  in  health. 
During  his  third  week  at  Atlantic  City,  however,  the  fever  returned 
in  an  irregular  form,  and  he  complained  at  times  of  violent  pain  in 
his  abdomen.  At  this  time  there  was  marked  tenderness  in  the 
right  iliac  fossa,  particularly  in  the  neighborhood  of  McBurney's 
point,  and  also  posteriorly,  back  of  the  appendix.  There  was  also 
some  rigidity  of  the  muscles  on  the  right  side  over  the  appendix. 
His  temperature  varied  from  103°  to  104°,  but  he  was  not  particu- 
larly restless.  His  tongue  was  fairly  clean,  but  there  was  a  com- 
plete loss  of  appetite.  At  this  time  the  appendicular  trouble  did 
not  seem  sufficient  to  account  for  his  high  temperature,  but  a  careful 
examination  of  every  organ  of  his  body  and  of  the  blood  failed  to^ 
reveal  any  cause  for  the  pyrexia.  At  the  end  of  the  first  week  in 
bed  his  tongue  became  foul,  his  lips  covered  with  sordes,  the  tem- 
perature on  one  or  two  occasions  rose  nearly  to  105°,  and  he  devel- 
oped the  typical  rose  spots  of  typhoid  fever,  the  appendicular 
irritation  and  inflammation  having  been  treated  during  the  pre- 
ceding week  by  the  application  of  ice-bags.  One  week  after  the 
symptoms  of  typhoid  fever  became  well  marked,  distinct  appen- 
dicular tenderness  partly  disappeared,  and  at  the  end  of  the  third 
week  had  entirely  disappeared.     Recovery  followed. 

A  case  such  as  this  is  of  interest  because  it  illustrates  the  fact 
that  it  is  sometimes  necessary  to  make  a  differential  diagnosis 

iBossard.  Ueber  die  Verchwiirung  unci  Durchborung  desWurmfortsatzes.  Thesis,  Zurich,. 
1869. 


77//';  N/<:nvo(/s  svst/'LM  159 

between  (.yplioid  I'cvcr  iuid  npixndicil  is,  ;uir|  ||i;il,  lyplioid  I'rjver 
and  appendicitis  may  exist  side  \>y  side. 

Ascites. — MePliedran/  of  MontrenI,  luis  rcfcjilly  rej>ortefl  four 
eases  of  ascites  diirinn-  iiiicoinf)Iicjitcd  typlujifl  fever.  'J'liis  corn- 
plication  appeared  durino'  (lie  lieijrlit  of  (lie  feWrile  |)roeess,  existed 
for  some  days,  and  disappeared  without  any  cause  for  its  iippejir- 
ance  beiiin;  found. 

Nervous  System  in  the  Developed  Stage  of  the  Disease. 
Delirium. — 'i'lie  tiervous  disturbances  vary  ^readw  In  tlif; 
average  ease  tliere  is  in  the  early  j)art  of  the  onset  no  inenfal  change, 
save  that  of  unfitness  for  mental  occupation,  with  dreamful  sleep 
which  is  apt  to  be  restless.  Later,  the  patient  continually  dozes  oflF, 
yet  awakens  easily,  and  for  a  moment  may  be  a  little  confused 
between  the  mental  impressions  left  on  his  brain  by  the  dream  and 
the  conditions  he  finds  about  him  on  returning  to  consciousness. 
Still  later,  if  the  attack  is  marked,  he  becomes  more  apathetic  when 
awake,  less  easily  aroused  when  asleep,  and  often  delirious  in  his 
sleep,  his  dreams  being  evidently  vivid,  so  that  he  keeps  muttering 
the  conversation  he  thinks  he  is  actually  having,  or  calls  out  loudly, 
as  his  dream  seems  to  lead  him  to  a  point  where  an  imperative  call 
or  sudden  action  is  needed.  Sometimes  the  delusions  in  the  delirium 
amount  to  imperative  conceptions,  and  the  patient  believes  that  he 
is  away  from  home  and  must  return  there  at  once,  or  that  he  is  being 
restrained  by  force,  or,  again,  that  some  member  of  his  family  is  in 
distress  and  needs  his  aid  or  is  calling  for  him.  Often  this  form  of 
mental  disturbance  is  painful  to  witness,  difficult  to  overcome,  and 
harassing  to  the  patient.  In  these  cases  the  hands  may  be  moved 
continually,  as  if  to  illustrate  the  views  of  the  patient.  Such  cases 
are  apt  to  be  grave  if  for  no  other  reason  than  that  they  exhaust 
themselves  if  relief  is  not  given.  The  more  encouraging  type  of 
delirium  is  of  the  quiet,  muttering  form,  as  if  the  patient  was  gently 
"talking  in  his  sleep"  as  in  health,  and  this  may  be  taken  as  the 
natural  form  of  delirium  in  the  disease.  Later,  the  stupid  condition 
may  become  more  and  more  marked  in  some  cases,  and  absolute 
mental  stillness  is  reached,  in  which  only  hard  shaking  or  loud 
calling  will  arouse  the  patient. 

1  MePliedran     American  Journal  of  the  Medical  Sciences,  November,  1908. 


160  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

On  the  other  hand,  even  in  severe  cases  the  mental  state  often 
remains  but  Httle  disturbed  throughout  the  entire  iUness,  and  in  the 
majority  the  beginning  mental  apathy  is  largely  put  aside  by  the 
proper  use, of  cold  sponging  or  plunging. 

Aside  from  the  mental  hebetude  of  most  cases  of  typhoid  fever, 
which  may  be  considered  to  represent  the  ordinary  mental  signs  of 
this  disease,  we  may  have  remarkable  clearness  of  intellect,  so  that 
at  no  time,  even  when  waking  from  a  heavy  sleep,  is  the  patient's 
mind  clouded,  but  it  is  a  curious  fact  that  some  of  these  patients 
who  seem  to  be  mentally  clear  all  through  an  attack  state  after  it  is 
over  that  they  have  a  very  indistinct  recollection  of  the  occurrences 
which  took  place. 

There  can  be  no  doubt  that,  as  a  rule,  the  mental  state  is  a  fair 
index  to  the  severity  of  the  malady,  and,  therefore,  the  greater  the 
perversion  of  the  mental  process  the  more  grave  the  prognosis. 
So  far  as  delirium  itself  is  concerned,  Liebermeister  found  that  in 
983  cases  without  noteworthy  brain  symptoms  only  about  3.5  per 
cent,  died;  that  in  191  cases  with  mild  delirium  at  times,  19.8 
per  cent,  died,  and  in  43  cases  in  which  stupor  or  coma  was 
present,  70  per  cent.  died.  Zenner^  asserts  that  in  cases  of 
severe  delirium  the  mortality  reaches  50  per  cent.,  and  when  the 
delirium  is  complicated  by  stupor,  almost  70  per  cent.;  that  the 
mortality  of  initial  delirium  approximates  30  per  cent.,  while  that 
occurring  during  the  first  week  of  the  fever  is  over  40  per  cent. 

It  seems  to  us  that  these  statistics  give  a  false  impression  as 
to  the  danger  of  these  symptoms  of  the  disease.  These  figures, 
however,  express  the  gravity  of  marked  mental  symptoms,  and  also 
throw  light  on  the  relative  frequency  of  the  mild  and  severe  affec- 
tions of  the  brain. 

Delirium  is  largely  dependent  upon  the  susceptibility  of  the 
individual  to  the  infection  and  to  the  febrile  movement.  Many 
persons  are  readily  made  "flighty,"  to  use  the  popular  term,  by 
fever  of  less  than  103°,  while  others  withstand  greater  fever  than 
this  with  impunity.  A  delirium  in  a  child,  of  the  active  talkative  or 
complaining  type,  does  not  possess  grave  significance  if  the  fever 
be  high  enough  to  be  its  cause,  since  the  mental  disturbance  is 
probably  due  to  the  temperature,  or  if  this  symptom  occurs  in  a 

1  Zenner.    American  Lancet,  January,  1889. 


77/ A'  N/'j/iVOf/s  hysti<:m  161 

nervotis  woman  or  inmi  i(,  is  nol  ol"  is^vcui  iiri|)()i(;iiKc  unless  if.  bf;  so 
persistent  and  lon^  coiiliinicd  lli;il  ihc  loss  ol"  siccj)  jiiid  i.i'k  of  rest 
exhausts  the  patient. 

A  form  of  (Iciii-iiim,  iisimlly  seen  in  liyslftic;il  women  ;in(|  eliil- 
dren,  whieh  resembles  tiie  condilion  of  (lie  j>atierit  suffering  from 
belladonna  poisoninj^,  sometimes  oeeurs,  in  which  there  is  mueh 
restlessness  and  tossing  of  the  body,  with  great  volubility  and 
incoherent  screaming,  which  may  seem  most  alarming,  but  which 
is  not  as  dangerous  an  omen  as  its  severity  would  indicate.  As  it 
is  usually  seen  in  the  early  stages  it  in  no  wise  is  indicative  of  pro- 
found nervous  exhaustion,  but  rather  of  an  ill-balanced  nervous 
system  upset  by  the  nervous  disturbance  of  the  infection. 

In  severe  cases  that  condition  of  ceaseless  mental  activity  in  a 
semistuporous  mind,  called  "coma  vigil,"  is  often  present.  It  is 
an  indication  of  grave  infection,  as  a  rule. 

Striimpel  asserts  that  "actual  insanity  is  not  infrequent  during 
the  course  of  typhoid  fever,"  and  that  it  generally  takes  the  form 
of  a  melancholia.  Taty^  records  a  case  of  what  he  calls  the  melan- 
cholic form  of  typhoid  fever,  the  diagnosis  being  confirmed  by  the 
Widal  reaction  and  other  characteristic  symptoms.  The  patient 
was  restless,  had  loss  of  appetite,  was  delirious,  and  had  great 
mental  depression.  There  was  absolute  mutism  when  she  was 
examined,  and  she  refused  both  food  and  drink,  but  sleep  was 
relatively  good.  In  another  case  there  were  visual  hallucinations 
and  delirium,  with  melancholic  conceptions,  and  vague  ideas  of 
persecution.  Striimpel  also  records  a  case  of  hysterical  insanity 
in  a  young  girl,  which  broke  out  during  the  course  of  the  fever. 
(For  post-typhoid  insanity,  see  last  chapter,  by  Dr.  Dercum.) 

Hysterical  convulsions  have  been  recorded  as  complicating  the 
developed  stage  of  typhoid  fever;  thus  Remond  and  Coumenges' 
record  two  cases  of  this  character.  In  one,  a  young  woman  of 
distinctly  neurotic  character,  who  had  never  suffered  from  convul- 
sions, however,  developed  on  the  fifteenth  day  of  the  disease  uncon- 
sciousness, a  thready  pulse,  embarrassed  respiration,  and  severe 
hiccough,  so  that  the  physician  thought  the  patient  was  about  to 
die,  when  the  scene  suddenly  changed,  the  body  was  stiffened,  and 

1  Taty.    Lyon  Medicale,  1S97,  p.  291. 
-  Remond  and  Coiunenges.    Medical  Bulletin,  June,  1895. 
11 


162  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

a  violent  hysterical  convulsion  came  on.  Repeated  attacks  occurred 
on  subsequent  days  until  death  occurred  from  exhaustion. 

Durino;  February,  1899.  one  of  us  (Hare)  saw,  in  consultation 
with  Dr.  Loux,  of  Philadelphia,  a  oiH  in  the  third  week  of  tyj)hoid 
fever  with  typical  hysteria,  as  shown  in  (he  facial  expression  and  in 
the  attitude  of  her  botly.  Her  arms  were  abducted,  her  forearms 
completely  flexed  at  a  right  angle  with  the  arms,  and  her  hands 
completely  flexed  at  a  right  angle  with  the  forearms.  This  case 
showed,  nevertheless,  evidences  of  profound  toxaemia,  and  died  a 
few  days  later.  When  first  taken  ill  she  was  very  hysterical,  cried 
and  screamed,  and  repeatedly  asserted  if  she  got  typhoid  fever  she 
would  die. 

Hysterical  symptoms  may  be  present  in  children.  Thus,  De  Witt* 
reports  the  case  of  a  boy,  aged  twelve  years,  who  suffered  on  the 
twenty-third  day  from  marked  hysterical  symptoms,  supra-orbital 
neuralgia,  and  pain  and  stiffness  in  the  back,  the  symptoms  coming 
on  simultaneously  with  high  temperature. 

Headache. — The  headache,  usually  frontal  and  severe,  in  the 
early  days  of  onset,  may  continue  as  an  annoying  symptom  all 
through  the  attack,  but  rarely  possesses  its  severe  characteristics 
after  the  first  week.  Under  certain  circumstances,  however,  it 
remains  severe,  and  is  worthy  of  relief  and  careful  study,  since  it 
may  be  due  to  periostitis  of  the  skull,  to  abscess  of  the  middle  ear 
or  brain,  or  to  urtemia.  A  combination  of  more  or  less  active 
delirium  with  restlessness  and  disturbed  sleep  and  severe  pain  in 
the  head  should  make  a  careful  search  for  a  local  cause  necessary. 

In  some  cases  the  pain  extends  from  the  head  down  the  spine, 
even  to  the  sacrum,  and  from  there  down  the  legs,  particularly  along 
the  posterior  parts  and  in  the  bones.  This  pain  is  chiefly  seen  in 
onset  and  in  early  stages,  and  is  generally  absent  by  the  third  week. 

Meningitis. — Rarely  in  the  course  of  typhoid  fever  of  the 
uncomplicated  form  symptoms  of  irritation  or  inflammation  of  the 
meninges  of  the  brain  develop,  and  it  is  important  to  remember 
that  these  symptoms  may  arise  from  several  causes.  The  most 
common  of  these  is  congestion  and  engorgement  of  the  meningeal 
vessels  without  any  true  inflammatory  process;  the  next  most  com- 
mon form  is  that  due  to  the  extension  of  an  infection  from  abscess 

1  De  Witt.    Bulletin  de  I'Acad^inie  Royal  de  Mddecine  de  Belgique,  November  17,  1889. 


THE  NKRVOIJS  SVSThWf  ](;:', 

in  flic  middle  CMP;  Hie  lliiid  roriii  is  di;il  in  wliirji  dicrc  is  inrcrtion 
willi  the  .streplococcns  or  pncnniococcus,  ;ind  \cry  nirdy  \\c  find 
;i  ni<'ninn;i(i,s  due  lo  (lie  biicilliis  of  I'llx'ftli.  ( ).slcf  records  Uirce  cases 
in  which  he  inade  autopsies  in  susjX'cted  tyj^lxjid  nicnin^n'fis  and 
found  no  true  inflammation,  and  as  long  ago  as  1839  Tanpin  called 
attention  to  the  diflercnce  at  autopsy  between  the  appearance  of  the 
meninges  of  the  brain  in  death  with  meningeal  symptoms  due  to 
typhoid  fever  and  those  due  to  true  meningitis.  Jn  tyjjhoid  fever 
in  children  he  states  that  tlie  condition  is  one  of  effusion  uidiont 
hypenemia. 

Meningitis  in  children  complicating  typhoid  fever  was  written 
upon  as  long  ago  as  1825  by  Senn/  of  Geneva.  Three  of  his  cases 
are  evidently  cases  of  typhoid  fever,  while  in  others  there  is  doubt 
as  to  their  authenticity,  and  there  is  still  less  evidence  that  real 
meningitis  was  actually  present,  even  though  the  symptoms  were 
those  of  meningeal  irritation. 

Keller"  asserts  that  true  meningitis  in  a  child  can  be  differentiated 
from  typhoid  fever  with  meningeal  symptoms  by  the  fact  that 
"Kernig's  sign"  is  present  in  meningitis  and  absent  in  enteric 
fever. 

The  meningeal  symptoms  vary  greatly  in  their  severity  accord- 
ing to  the  meningeal  lesions  which  may  be  present.  In  the  majority 
of  instances  the  chief  signs  are  headache,  delirium,  some  muscular 
rigidity,  particularly  in  the  neck,  and,  it  may  be,  "lead-pipe" 
rigidity  in  the  arms  and  legs.  In  other  instances  the  patient  is  too 
deeply  stupefied  by  the  poison  of  the  disease  to  complain  of  head- 
ache, but  may  show  headache  by  rubbing  his  hands  over  his  head 
and  groaning,  after  which  he  may  pass  into  coma,  which  deepens 
until  death  occurs.  Very  rarely  does  the  pure  symptom-complex 
of  true  acute  meningitis  develop,  and  until  the  characteristic  squint, 
retraction  of  the  head,  and  pupillary  signs  are  present,  the  physician 
must  not  hasten  to  a  diagnosis  of  meningitis. 

On  the  other  hand,  the  symptoms  already  named  may  be  so 
typical  that  if  the  patient  is  brought  to  a  hospital  late  in  his  illness 
without  a  history,  he  may  present  so  little  of  the  typhoid  appearance 
and  so  much  that  of  meningitis  that  a  mistake  in  diagnosis  is  readily 

1  Senn.    Recherclies  sur  la  Meningite  Signe  des  Enfants,  1S25. 

-  Keller.    Revue  des  Maladies  de  TEnfanee,  September,  1S9S,  p.  450. 


164  WELL-DfJVELOPED  STAGE  OF  THE  DISEASE 

made.  To  tjiiote  Hirt:^  "Of  all  diseases  typhoid  fever  is  most  likely 
to  be  taken  for  meningitis,"  and,  again,  he  tells  ns  that  "we  might 
believe  that  at  least  the  characteristic  temperature-curve,  the 
splenic  enlargement,  and  the  rose  spots  would  be  sufficient  to  make 
a  mistake  impossible."  But  this  is  by  no  means  always  the  case; 
there  are  instances  in  which  typhoid  fever  cannot  with  certainty  be 
excluded,  and  then  the  differential  diagnosis  is  impossible,  except 
by  the  Widal  test  or  cultures  from  the  blood. 

So  certain,  however,  is  Money^  of  the  assertion  of  Hughlings 
Jackson,  that  the  knee-jerk  is  not  absent  in  typhoid  fever,  that  he 
uses  this  sign  as  a  point  in  differential  diagnosis.  Thus,  in  tuber- 
culous meningitis  he  states  that  it  disappears  and  then  reappears 
every  few  days,  and  that  this  inconsistency  of  the  reflex  favors  the 
diagnosis  of  tuberculous  meningitis  rather  than  typhoid  fever. 

The  possibility  of  confusing  meningitis  or,  rather,  meningeal 
symptoms  with  those  of  typhoid  fever  was  long  ago  discussed  by 
Taupin  in  1839,  and  he  points  out  that  in  such  cases  the  patient  has, 
in  meningitis  due  to  typhoid  fever,  no  convulsions,  no  strabismus, 
and  no  paralysis,  whereas  the  child  with  true  meningitis  has  all 
these  signs,  and  in  addition  a  variable  pulse,  a  scaphoid  belly,  an 
absence  of  pulmonary  catarrh,  and  a  face  which  is  alternately  red 
and  pale. 

Illustrative  of  the  supposed  rarity  of  true  typhoid  meningitis, 
however,  it  is  of  interest  to  note  that  from  1855  to  1887  there 
are  only  five  cases  of  this  affection  referred  to  in  the  Index  Cata- 
logue of  the  Surgeon-General's  Office,  and  as  none  of  these  were 
tested  bacteriologically  they  cannot  be  considered  bona  fide.  That 
meningitis  due  to  any  cause  in  typhoid  fever  is  rare  is  shown  by  the 
fact  that  out  of  2000  cases  in  Munich,  only  eleven  are  recorded  as 
suffering  from  meningitis.  Still  more  rarely  is  the  meningitis  due 
to  the  bacillus  of  Eberth,  for  Wolff, ^  in  174  cases  of  typhoid  fever 
which  were  subjected  to  bacteriological  examination,  only  found 
2.87  per  cent,  in  which  the  specific  bacillus  could  be  found  in  the 
meninges. 

Within  the  last   few    years   this  subject   has   been   admirably 

'  Hirt     Nervous  Diseases,  American  edition,  p.  18. 

2  Money.     Tlie  Lancet,  1889. 

»  Wolff.     Berliner  klinische  Woclienschrift,  1897,  No.  10. 


77//-;  NMRVOUS  SVSTh'M  Ifio 

discussed  by  ( )liliii;iclicr,'  of  ()lii(),  iitid  In'  K'ccii,'  of  I'lnlu- 
(l('l[)}iiji.  Olilrnaclicr  himself  reeonls  (wo  cases  in  wliieli  dutin^ 
tlu!  course  of  typlioid  f(!V(!r  menin^(;ul  syinplorris  (l(;veIoj>e(J,  and 
in  whicli  careful  bacteriological  research  revealed  heyoiid  all  douht 
the  bacillus  of  Eberth  in  tlu;  in(uiinges.  In  still  Miiodier  case 
recorded  by  Ohlrnncher  there  was  foinid  a  mixed  iid'eefion  by  flii.s 
bacillus  and  the  streptococcus. 

Only  a  limited  number  of  true  meningeal  infections  by  the  bacillus 
of  Eberth  of  an  undoubted  character  have  been  recorded,  which  is 
a  point  of  great  interest.  In  all  of  these  the  dura  mater  and  pia 
mater  appear  to  be  equally  affected,  and  the  effusion  was  in  at  least 
six  of  the  cases  purulent. 

Illustrative  cases  of  this  character  are  taken  as  follows  from 
Ohlmacher's  paper: 

"A  case  of  meningitis  occurring  in  the  course  of  typhoid  fever 
was  described  by  Kamen,^  in  1890,  in  a  soldier  who  entered  the 
hospital  after  having  been  ill  for  five  days.  A  severe  headache  set 
in  three  days  later,  followed  by  delirium  and  unconsciousness,  and 
death  occurred  eight  days  after  admission  to  the  hospital.  Aside 
from  acute  splenic  tumor  and  a  single  typhoid  ulcer  near  the  csecal 
junction  of  the  ileum,  the  postmortem  examination  showed  an 
extensive  purulent  leptomeningitis.  The  cultures  obtained  from 
the  spleen,  mesenteric  glands,  and  meninges  were  identical,  though 
only  the  potato  test  was  mentioned  as  having  been  employed  for 
identification.  The  following  year  Fernet^  reported  the  case  of  a 
woman  who  developed  headache,  delirium,  strabismus,  exophthal- 
mos, retention  of  urine,  and  irregularity  of  the  pupils  in  the  course 
of  typhoid  fever.  At  autopsy  the  characteristic  changes  of  t^'phoid 
fever  were  found  in  the  abdominal  cavity,  and  a  diffuse  serous 
meningitis  was  also  present.  It  is  claimed  that  typhoid  bacilli 
were  isolated  from  the  meningeal  fluid,  though  no  mention  is  made 
of  special  tests.  Silva^  likewise  observed  at  autopsy  in  a  female 
epileptic,  aged  ten  years,  a  serohemorrhagic  leptomeningitis  with 
a  lobar  pneumonia  and  the  ordinary  evidences  of  t}'phoid  fever. 

*  Ohimacher.    Journal  of  the  American  Medical  Association,  1S97,  p.  419. 
2  Keen.    Surgical  Complications  of  Typhoid  Fever. 

Kamen.    International  Ivliu.  Rundschau,  1890,  vol.  iv,  No.  3.  p.  9S;  No.  4,  p.  156. 
4  Fernet.    Le  Bulletin  Medical,  1891,  p.  653. 
6  Silva.    Riforma  Mediea,  1891,  vol.  iii,  No.  210. 


166  ^y  ELL-DEVELOP  ED  STAGE  OF  THE  DISEASE 

Typhoid  bacilli  were  isolated  from  the  nioninoes  and  carefully 
identified.  Still  another  case  was  reported  by  Honl/  who  found  a 
diffuse  purulent  leptomeningitis  in  a  twenty-one-year-old  woman, 
who  (lied  in  the  course  of  typhoid  fever.  An  exhaustive  differential 
examination  showed  the  only  bacterial  species  ()l)taiiuHl  from  the 
meningeal  exudate  to  be  Bacillus  typhosus. 

"Cases  essentially  similar  to  those  just  noted  have  been  reported 
since  1892  by  Vincent,'-  Hintze,^  Mensi  and  Carbone,^  Stuhlen,^ 
Tictine,®  Kuhnau,^  and  a  second  one  by  Kamen.* 

"Tictine  reported  two  cases  which  came  under  his  ol)servation, 
and  he  also  produced  a  purulent  meningitis  in  animals  by  means 
of  sulxlural  inoculations  with  typhoid  cultures.  The  second  one  of 
his  cases  differs  from  all  others  in  that  the  patient  was  perfectly 
conscious  during  the  last  week  of  his  life. 

"Profound  unconsciousness,  delirium,  coma,  and  often  reten- 
tion of  urine  are  the  symptoms  most  often  described  in  these  cases. 
Other  symptoms  which  might  suggest  an  actual  meningitis  are 
usually  insignificant,  and  can  scarcely  be  looked  upon  as  of  diag- 
nostic import.  To  this  rule,  however,  the  case  mentioned  by 
Mensi  and  Carbone  is  a  notable  exception.  Their  patient  was  a 
girl,  aged  six  years,  who  had  been  ill  nine  days  before  entering  the 
hospital.  The  patient  ran  the  course  of  a  moderate  attack  of 
typhoid  fever,  reaching  the  stage  of  apyrexia  four  weeks  after 
coming  to  the  hospital.  Four  days  later  a  violent  chill  occurred, 
with  intense  headache  and  a  temperature  of  39.2°  C.  Delirium, 
opisthotonos,  contractions,  amblyopia,  and  dilated  non-responsive 
pupils  were  successively  noted,  together  with  a  herpes  labialis, 
paresis  of  right  face,  and  retraction  of  abdominal  wall.  Great 
prostration  followed,  and  death  occurred  four  days  after  the  onset 
of  this  relapse.  The  autopsy  showed  a  fibrinopurulent  cerebro- 
spinal meningitis,  with  dilatation  of  the  lateral  ventricles,  and  a 
bronchitis  of  the  medium  and  smaller  bronchioles.     Numerous 

1  Honl.    Centralblatt  fiir  BacterioloKie,  1893,  Band  xiv,  p.  767. 

*  Vincent.    Schmidt's  Jahrbucher,  1893,  Band  ccxxxvii.  No.  2. 

'  Hintze.    Centralblatt  fiir  Bacteriologie,  1893,  Band  xiv,  No.  14. 

*  Mensi  and  Carbone     Kifornia  Medica,  1893,  i,  14. 

'  Stulilen.     Berliner  klin.  Wochenschrift,  1894,  No.  15. 
"Tictine.    Archives  de  Med.  Experiment,  1894,  vi,  1. 
7  Kuhnau.    Berliner  klin.  Wochenschrift,  1896,  No.  2.5. 

*  Kamen.    Centralblatt  fiir  Bacteriologie,  1897,  1st  abtheilung.  Band  xxi,  Nos.  11  and  12. 


Till':  ni<:r.V()ijs  svsticm  107 

typical  typhoid  ulcers  iti  tlic  .stage  of  lie;iliiig  were  founfl  In  ihe 
ileuiii  and  colon;  the  Jnesentoric  /^hiiid.s  wen;  svvolN-n  and  .-lol't, 
and  there  was  sof'teninj)^  of  the  spleen.  A  tFiorongh  l);icteriolf>/^ic;d 
examination  of  ihe  nienino(>iil  e.xndale  resiilled  in  finrh'/i;.'  (v|>li()id 
bacilli  as  the  sole  bactei'ia!  inliahitanl." 

In  rare  cases  where  death  has  occnrre(|  IVom  ineninifili.s  wilhont 

o 

enteric  fever  being  suspected,  (lie  antoj)sy  lias  revealed  the  bacillus 
of  Eberth  to  be  its  cause,  as  has  been  reported  by  Curschmann. 
Such  instances  have  been  recorded  l)y  Ohimacher  and  ;ire  of  irifer- 
est.    He  tells  us  that: 

"In  the  course  of  a  study  of  meningitis,  Neuniaini  jiiifj  Schaef- 
fer^  (LS87)  found  an  extensive  ])in'ulent  leptomeningitis  in  a  woman 
brought  to  the  hospital  unconscious,  and  who  died  in  a  few  hours 
without  furnishing  any  history.  No  lesions  of  typhoid  fever  were 
found,  but  pure  cultures  of  a  bacillus  were  obtained  from  tlie 
meninges,  and  these,  the  authors  were  led  to  believe,  were  of 
Bacillus  typhosus,  from  the  general  character  and  from  the  positive 
results  of  the  potato  and  fermentation  differential  tests.  A  verv 
similar  case  was  reported  soon  after  by  Adenot,"  in  which  a  woman 
presented  profound  symptoms  of  cerebral  infection  and  died  in 
eight  days.  Absolutely  no  typhoidal  lesions  were  present  in  the 
intestines,  spleen,  and  mesenteric  glands,  but  from  the  seropuru- 
lent  exudate  in  the  soft  meninges  a  bacillus  resembling  the  typhoid 
organism  was  obtained.  The  only  differential  test  here  applied 
was  the  growth  on  potato,  and  we  now  know  that  this  is  not  suJ9B- 
cient  to  identify  the  bacillus  of  typhoid  fever.  The  case  recorded  by 
Balp^  also  belongs  in  the  same  category  with  those  of  the  authors 
just  noted.  He  found  a  diffuse  purulent  meningitis  in  a  patient 
dying  five  days  after  a  fracture  of  the  skull,  and  in  the  exudate  a 
bacillus  resembling  the  Eberth  organism  was  found,  together  with 
a  species  of  diplococcus.  The  phenol  and  indol  tests  are  all  that 
Balp  mentions  having  used  for  differentiation." 

Kerr  and  Moffitt^  have  reported  the  case  of  a  man,  aged  twentv- 
eight  years,  who  on  admission  was  found  in  a  stupid  mental  state.    He 

1  Neumann  and  Schaeffer.    Virchow's  Archiv  1887,  Band  cix,  Heft  3,  p.  477. 

-  Adenot.    Archives  de  Med.  Experiment,  et  d'Anat.  Pathol.,  1889,  i,  656. 

3  Balp.    Rivista  Generale  Ital.  et  de  Chir.  Med..  1890.  No.  17,  p.  406. 

*  Kerr  and  MofRtt.    Journal  of  the  American  Medical  Association,  March  IS,  1S99. 


168  WELL-DEVELOPED  STAGE  OF   THE  DISEASE 

had  been  ill  for  a  period  of  three  or  four  weeks.  He  had  been  seized 
with  o-eiieral  weakness,  fever,  loss  of  appetite,  headache,  and  pain 
in  the  right  iliac  region,  no  cough  or  nose-bleed.  The  cause  of  his 
entrance  to  the  hospital  was  the  pain  in  the  right  iliac  region,  weak- 
ness, and  headache.  He  was  found  to  be  slightly  demented,  and 
answered  questions  slowly,  articulating  poorly,  but  there  was  no 
real  aphasia.  The  fever  ran  an  erratic  course,  resembling  tuber- 
culous meningitis  more  closely  than  typhoid  fever.  The  pulse  was 
fairly  slow  and  dicrotic.  There  were  no  spots  and  no  eye  symp- 
toms; there  was  persistent  diarrhoea  of  the  pea-soup  variety,  and 
rapid  emaciation;  the  Widal  test  was  obtained,  and  autopsy  showed 
a  few  old  ulcers  in  the  right  ileum  which  were  certainly  six  or  eight 
weeks  old;  the  brain  was  covered  with  a  thick  pm-ulent  exudate, 
yellow-red  in  color.  Cultures  were  made  which  showed  motile 
bacilli  giving  the  negative  glucose  test,  but  clumping  Avith  typhoid 
serum. 

Boden^  has  reported  the  case  of  a  fourteen-year-old  child  who 
suffered  from  typhoid  fever  and  was  admitted  to  the  Augusta 
Hospital  of  Cologne  at  approximately  the  end  of  the  first  week  of  the 
disease.  There  was  hypera^sthesia  of  the  entire  body,  and  cyanosis. 
Two  days  later  there  was  a  severe  epileptic  attack  and  deep  stupor, 
with  left-sided  abducens  and  facial  paralysis,  with  loss  of  pupillary 
reflex  and  the  patellar  reflex.  Death  occurred  three  days  later, 
and  the  autopsy  revealed  marked  typhoid  fever  of  the  first  week, 
and  meningitis  serosa,  a  large  amount  of  clear  serum  being  present 
at  the  base  of  the  brain.  The  brain  w'as  normal,  the  ventricles  were 
distended.  From  the  fluid  in  the  ventricles  a  pure  culture  of  the 
bacillus  of  Eberth  was  obtained;  this  fluid  also  gave  the  Widal 
test.  Boden  states  that  only  five  cases  of  this  character  have  been 
reported,  namely,  those  of  Stuhlen,  Kugnan,  Daddi,  Hintz,  and 
Honl. 

Dubert,  in  1901,  made  "Meningitis  during  the  Course  of  Typhoid 
Fever"  the  theme  of  his  Paris  Thesis,  and  Cole^  reviewed  the  litera- 
ture in  reporting  his  case  from  the  Johns  Hopkins  Hospital.  He 
mentions  14  cases  reported  by  various  authors  in  which  there  had 
been  present  fibrinopurulent  or  hemorrhagic  purulent  meningitis, 

1  Boden.     Miincliener  medicinisclie  Wochensi.-hrift,  February  28,  1899. 

2  Cole.    .lohn.s  Hopkins  Hospital  Reports,  1905. 


THE  NERVOUS  SYSTEM  K;0 

with  (^('iicriil  lyplioid  lesions.  Ilcjilso  iih-iiIiohs  I.'»  oIIht  rnsfs  ol' 
simikir  [)unjl('iit  inciiinoitis,  in  wliicli,  however,  (lie  i<Jeiififie;ilion 
of  the  typhoid  bacillus  was  not  so  (;('r(;iin,  jind  of  scvend  other 
cases  in  wliich  there  was  mixed  infection  with  (he  typhoifj  hiK-illij.s. 

Sometimes  the  infection  chiefly  involves  the  mein'n^es,  intestinal 
lesions  being  absent.  Thus,  Neumann  and  Schaeffer,'  RavenM,^ 
Staubi,^  Henry  and  Rosenberger,''  and  Lavenson'*  have  all  reported 
cases  of  purulent  cerebrospinal  meningitis  due  to  tyj)lioi(l  iiifee(if>n, 
without  the  usual  intestinal  lesions  of  the  disease,  and  have  been 
able  to  isolate  the  bacillus  typhosus  from  the  exudate  of  the  local 
lesion. 

The  more  frequent  use  of  lumbar  puncture  as  an  aid  to  accurate 
diagnosis  has  been  an  important  feature  in  revealing  the  true 
nature  of  some  of  these  obscure  meningeal  cases. 

The  meningitis  complicating  typhoid  fever  usually  develops  in 
the  third  or  fourth  week,  and  in  the  great  majority  of  instances  in 
which  the  complication  has  appeared  the  patient  was  under  thirty 
years,  and  usually  between  twenty  and  thirty  years,  the  period  in 
which  typhoid  fever  is  most  commonly  seen. 

In  every  case  of  true  typhoid  meningitis,  so  far  as  recorded, 
death  has  occurred,  but  this  is  a  statement  which  does  not  possess 
as  great  prognostic  value  as  would  appear  at  first  glance,  since  an 
absolute  diagnosis  of  true  typhoid  meningitis  can  only  be  made 
during  life  by  lumbar  puncture,  the  positive  test  being  the  bacterio- 
logical examination  of  the  meningeal  fluid.  Nevertheless,  the 
presence  of  marked  meningeal  symptoms  is  of  the  gravest  import  in 
all  cases. 

Very  rarely,  because  of  degenerative  changes  in  the  vessels,  a 
hemorrhagic  effusion  into  the  meninges  of  the  brain  takes  place, 
but  this  does  not  commonly  produce  marked  symptoms  unless  it  is 
profuse. 

Under  the  name  of  "irritation  of  the  brain  with  depression  of 
temperature,"  a  condition  has  been  described  by  Liebermeister, 
which  comes  on  in  about  the  second  week  of  the  disease  when  the 

1  Nevunann  and  Schaeffer.    Virchow's  Archiv,  1SS7,  Band  cix. 

2  Ravena.    II  Polyclinico,  May,  1904. 

5  Staubi.    Deut.  Arch.  f.  klin.  Med.,  vol.  Ixx.xii. 

*  Henry  and  Rosenberger.    American  Journal  of  the  Medical  Sciences,  February,  1908. 

'  Lavenson.    University  of  Pennsylvania  Medical  Bulletin,  April,  190S. 


170  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

svinptoiiis  are  most  violent,  ami  in  j)atifnts  who  liave  had  pro- 
lonijecl  liit^h  temperature.  The  pupils  lose  their  reaction  to  light, 
and  svuiptonis  of  nienini;-eal  irritation  develop,  or  in  their  })laee 
marked  mental  clianti'es  occur,  the  i)atient  heconiiiii;'  maniacal  or 
deeply  melancholic.  INIore  noteworthy  than  all,  the  temperature 
suddenly  falls  almost  to  normal,  and  remains  there  for  several 
davs,  as  long  as  the  symptoms  named  continue,  when  it  rises  again 
to  the  j)()iiUs  usually  met  with  at  that  ])cri()d  of  the  malady,  and 
proceeds  as  before.  Such  cases  are  very  rare.  In  his  enormous 
experience,  Liebermeister  only  met  with  "eight  or  ten  cases." 

Cerebral  Thrombosis  and  Embolism. — Richardson^  has 
recorded  a  case  of  a  man,  aged  forty-three  years,  who  in  the  third 
week  of  the  disease  sufi'ered  from  intense  headache,  chiefly  in  the 
left  temporal  region,  accompanied  by  collapse  and  a  subnormal 
temperature.  He  rallied  under  stimulating  treatment,  but  two 
davs  later  there  was  marked  coma,  contracted  pupils,  particularly 
that  on  the  right  side.  Convulsive  movements  were  also  present 
on  the  left  side,  chiefly  in  the  leg.  Later,  the  right  side  of  the  body 
was  involved.  He  died  five  days  after  this  complication  arose,  and 
the  autopsy  revealed  no  signs  of  meningitis,  but  the  veins  of  the  pia 
mater  were  distended  with  five  clots,  one  of  which  was  particularly 
large  and  lay  along  the  Rolandic  fissure.  The  sinuses  were  patulous. 
In  the  first  left  temporal  convolution  there  w^as  a  small  abscess.  No 
clots  were  found  in  the  sinuses.  There  are  three  interesting  points 
in  this  case:  First,  the  development  of  convulsions  of  a  more  or  less 
localized  character  in  the  course  of  typhoid  fever;  second,  the  fact 
that  there  was  general  thrombosis  of  the  intracranial  veins  without 
the  sinuses  being  involved;  and  third,  the  entire  absence  of  an> 
signs  of  meningitis  at  the  autopsy,  although  the  symptoms  during 
life  seemed  to  indicate  the  presence  of  this  condition.  This  last 
fact  is  of  particular  interest  in  view  of  the  fact  w^orthy  of  recollection, 
and  already  pointed  out,  that  although  meningeal  symptoms  may  be 
well  marked  in  enteric  fever,  true  meningitis  is  comparatively  rare. 
Quite  as  important  is  the  fact  that  the  lesion  was  in  the  veins. 

When  it  is  remembered  that  throml^osis  of  the  cerebral  sinuses 
is  the  usual  lesion,  that  such  an  authority  as  Gowers^  questions 

1  Richardson.    Journal  of  Nervous  and  Mental  Disease* 
*  Cowers.    Diseases  of  the  Nervous  System. 


rilN  N/'JRVOUS  SYSTEM  171 

wlicdicr  [)i'Itn;iry  venous  I  liroinljosis  ever  occurs  wlllioiil  inir^ 
i,lir(>iiil)osi,s,  iuid  lliat  Miic(!WCM,'  in  his  cl;issic;il  work  on  tlic  sur^^crv 
of  (lie  ln'itin  iUid  cord,  says  nodn'n^r  of  niuranfic  priinarv  vr-noiis 
tlii'onihosis,  (lie  rai'ily  of  lliis  condidon  is  notcvvordiy.  Ilirl'  says 
it  ina.y  occur  in  the  veins  as  well  as  (lie  sinuses,  l)ui  l)aMa,'  li(;.sen- 
thal/  Gray,''  and  Brill"  fail  to  describe  it. 

Thrombosis  of  the  cere})ral  sinuses  is  usually  said  lo  be  due  lo 
an  exhausting  disease  or  to  inrecdon.  In  such  a  case  as  that  just 
described  both  these  factors  were  j)reseiil. 

Finally,  it  is  interesting  to  note  that  an  addidonal  factor  I/i  diis 
case  still  further  eomj)lieated  the  clinical  diagnosis,  namely,  a 
history  that  the  patient  had  had  two  severe  head  injuries,  one  twelve 
years  before  and  one  two  months  before. 

A  case  of  possible  thrombosis  occurred  some  time  since  in  the  wards 
of  the  Jefferson  Hospital,  in  the  person  of  a  student,  aged  twenty 
years.  He  came  under  observation  on  the  third  day  of  his  illness, 
and  for  the  next  eleven  days  passed  through  a  marked  but  moderate 
attack  of  typhoid  fever.  On  the  fifteenth  day  of  the  disease  he  was 
suddenly  seized  with  hurried  stertorous  breathing,  rising  from  26 
to  48  respirations  a  minute,  and  his  pulse  rose  from  the  neighbor- 
hood of  116  to  148,  and  finally  to  160.  He  developed  hemiplegia  of 
the  right  side,  unconsciousness,  contracted  pupils,  and  the  eyeballs 
were  deviated  upward.  Both  pulmonary  bases  posteriorly  filled 
up  rapidly,  becoming  dull  on  percussion  and  developing  coarse 
rales.  The  skin  became  cyanotic,  and  blood-stained  mucus  was 
expelled  from  the  mouth  by  the  stormy  respirations.  He  died  about 
ten  hours  after  these  symptoms  began,  with  marked  retraction  of  the 
head  and  neck.  No  autopsy  was  permitted,  but  from  the  symptoms 
we  are  inclined  to  regard  the  condition  as  due  to  embolus  or  throm- 
bus in  the  lung  causing  infarction,  and  in  the  cerebral  vessels 
causing  the  paralytic  and  other  nervous  symptoms. 

Lopriore^  has  reported  a  case  of  typhoid  fever  in  a  girl,  aged  ten 
years,  in  which  on  the  seventeenth  day  of  the  disease  the  patient 
developed  aphasia  and  great  restlessness;  the  child  could  understand 

1  Macewen.     Diseases  of  the  Nervous  System. 

2Hirt.    Ibid.  ^  D^na.    Ibid.  •»  Rosenthal.    Ibid.  =  Gray.    Ibid. 

**  Brill.    Article  in  Dercum's  Diseases  of  the  Nervous  System. 

'  Lopriore.    Gazzetta  degli  ospedali  e  deUe  cliniche,  January  5,  1899,  p.  25. 


172  WELL-DEVELOPED  STAGE  OF   THE  DISEASE 

what  was  saitl  to  it,  and  there  was  no  j)aralysis  of  any  of  its  hmbs; 
the  motor  aphasia,  however,  histed  for  a  period  of  a  month  and  a 
hah',  when  tlie  ehikl  was  gradually  taught  to  speak  again.  Lopriore 
believes  that  this  case  was  due  to  a  microbic  embolus,  which  plugged 
a  branch  of  the  Sylvian  artery  and  thereby  infiuenced  the  Broca 
centre. 

Convulsions,  generalized  or  local,  with  coma  and  delirium,  may 
arise  from  thrombosis  of  the  cerebral  sinuses  or  of  the  cerebral 
arteries,  but  they  are  very  rare  from  any  cause  (see  hemiplegia 
article  for  cases).  Murchison  only  met  with  them  in  six  cases  out 
of  2960  cases.  If  due  to  the  lesions  named,  they  result  in  a  fatal 
termination  in  the  near  future.  In  Osier's  case  death  followed 
convulsions  produced  by  thrombosis  of  the  branches  of  the  left 
middle  cerebral  artery  in  twelve  hours.  If  they  occur  in  neurotic 
children  or  females  the  outlook  is  not  so  gloomy,  as  they  probably 
do  not  depend  upon  an  actual  lesion  in  the  brain.  Thus,  West  has 
recorded  a  case  in  which  convulsions  developed  in  the  third  week 
of  typhoid  fever  in  a  child,  recurring  on  two  successive  days.  These 
were  followed  by  hemiplegia,  which,  however,  gradually  disappeared 
in  foiu-  days.    Recovery  eventually  took  place. 

Bulbar  Paralysis. — A  possible  cause  of  sudden  death  during 
t>^hoid  fever,  or  in  convalescence,  is  said  to  be  bulbar  paralysis. 
Thus,  Latil^  mentions  a  woman,  aged  forty-two  years,  who  suffered 
from  a  severe  attack  of  typhoid  fever  with  hyperpyrexia  and  extreme 
prostration,  but  not  equally  marked  nervous  symptoms.  On  the 
eighteenth  day  of  the  attack  she  suffered  from  paralysis  of  the 
bladder,  and  on  the  forty-second  day  from  tetanic  contraction  of 
the  masseter  muscles,  with  dysphagia  and  a  nasal  voice.  The  res- 
piration became  shallow  and  rapid,  the  patient  seemed  greatly 
oppressed,  had  an  anxious  face,  and  asphyxia  so  rapidly  increased 
that  death  occurred  in  a  few  hours.  It  seems  to  us  that  there  is 
grave  doubt  whether  this  case  was  not  one  of  peripheral  nerve 
paralysis  rather  than  a  central  lesion,  but  that  sudden  death  may 
occur  from  a  small  lesion  occurring  in  the  medulla  is  illustrated 
by  a  case  which  has  been  reported  by  Libouroux,^  in  which  sudden 
death  occurred  during  the  third  week  of  the  disease,  and  an  autopsy 

'  Latil.    Revue  Gdn^rale  de  Clinique  et  de  Th^rapeutique,  March  21,  1890. 

2  Libouroux.    Gazette  Hebdomadaire  de  Mddecine  et  de  Cliirurgie,  March  5,  1890. 


77//';  Nl'J/iVOUS  SV.STKM  ]7'4 

revealed  ii  sniiill  li(iiiorili;i^c  in  (lie  (loor  of  llic  f"()ii((li  vcuhif-lo. 
There  was  no  other  coiHlilion  wliicli  could  ;Hroiini  for  flic  .sudden 
death  of  the  patient. 

Knee-jerks. — No  less  authorities  than  Iliij^lilin^s  Jaeksfjn  and 
Angel  Money  have  stated  (liat  luiee-jerks  are  never  hrst  in  ent(;rie 
fever.  This  is  scarcely  correct,  for  we  have  seen  cases,  not  ex- 
cessively ill,  in  which  they  were  al)sent  for  days  at  a  time  as 
completely  as  in  ataxia  oi-  some  cases  of  (habetes. 

Restlessness  and  Insomnia,  often  complained  of  by  the  patient, 
is  much  more  rare  than  the  complaints  would  indicate.  Watchful 
nurses  will  report  repeatedly  and  truthfully  that  such  patients 
sleep  the  greater  part  of  the  night  and  day,  and  the  lack  of  sleep 
is  either  a  delusion  or  else  the  few  waking  moments  seem  pro- 
longed into  hours  to  the  patient.  On  the  other  hand,  persistent 
insomnia  marked  by  unnatural  quiet,  the  patient  lying  with  the 
eyes  closed,  may  lead  the  careless  attendant  to  report  prolonged 
sleep,  when  in  reality  true  sleeplessness  is  present.  When  insom- 
nia is  due  to  feeble  circulation,  the  use  of  alcohol  stimulation  will 
usually  relieve  the  condition,  and  morphine  may  be  useful. 

We  come,  then,  to  the  consideration  of  subsultus  tendinum  and 
carphologia.  Both  of  these  are  signs  of  grave  illness,  particu- 
larly the  latter,  but  they  are  neither  of  them  as  mortal  in  their 
prognostic  import  as  the  older  authors  thought,  foi^^tients  with 
these  symptoms  often  get  well. 

Epilepsy. — Tyson  asserts  that  in  cases  of  t}^hoid  fever  in  which 
the  patient  also  suffers  from  epilepsy,  the  epileptic  attacks  are  apt 
to  be  greatly  multiplied  in  the  early  periods  of  the  disease;  to  cease 
as  the  disease  progresses,  and  to  remain  absent  until  convalescence 
is  established. 

Neuritis. — Neuritis  may  come  on  in  typhoid  fever  in  the  latter 
part  of  the  third  week  or  in  the  fourth  week,  but  it  is  generally 
a  complication  noted  during  convalescence.  (See  chapter  on 
Convalescence.) 

Almost,  if  not  equally  rarely,  pain  in  the  muscles  is  developed 
as  the  result  of  a  myositis. 

Paralysis. — Paralysis  arising  from  t>'phoid  fever  usually  comes 
on  during  the  very  latest  stage  of  the  disease  or  in  convalescence, 
and  is  so  distinctly  an  after-symptom,  as  a  rule,  that  it  will  be 


174  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

considered  under  the  division  in  which  the  hite  eouiplications  and 
sequels  are  discussed.  Rarely,  however,  as  will  be  pointed  out, 
the  loss  of  power  may  occur  in  the  middle  of  the  febrile  attack. 

As  an  evidence  of  the  rarity  of  extensive  and  permanent  paralysis 
of  the  extremities  complicating  or  following  tyj)hoid  fever,  we 
may  quote  the  statement  of  Alexander,  who,  during  an  experience 
of  ten  years  and  a  half  in  the  medical  clinics  at  Breslau,  did  not 
meet  with  a  single  case  of  paralysis  among  3900  typhoid  patients. 
(Hemiplegia  in  typhoid  fever  is  discussed  later  on  in  the  volume). 

The  Skin  in  the  Well-developed  Stage  of  the  Disease.— The 
rash  of  typhoid,  which  usually  develops  al)Out  the  seventh  or 
ninth  day,  is  usually  characterized  by  its  rose-spot  appearance.  A 
delicate  pink  hyperjcmia  of  the  skin  is  all  that  it  amounts  to  in 
many  cases,  and  the  rash  may  be  so  sparse  as  only  to  be  found  by 
the  most  careful  examination  of  the  whole  body,  when  a  few  spots 
will  reward  the  search.  They  are  usually  found  on  the  belly,  the 
chest,  or  the  back.  In  other  cases  the  spots  are  very  profuse,  being 
present  literally  by  the  thousand.  This  is  rare.  During  certain 
epidemics  the  writers  have  been  impressed  by  the  fact  that  the  rash 
has  been  unusually  profuse  and  exceedingly  coarse.  The  individ- 
ual spots  have  been  not  only  large  and  well  defined,  but  distinctly 
elevated  and  maculopapular  to  an  extraordinary  extent.  Further, 
in  these  cases  repeated  crops  of  this  roseola  have  repeatedly 
appeared  as  the  disease  progressed.  The  rose  rash  of  enteric  fever, 
however,  is  so  typically  separated  as  to  its  various  spots,  and  there 
is  so  little  coalescence,  that  few  of  the  general  forms  of  rose  rash 
resemble  it. 

In  rare  instances,  however,  the  rash  does  coalesce,  and  then  may 
resemble  measles,  and  in  still  other  cases  where  its  papular  form 
is  lacking  this  coalescence  may  render  it  very  much  like  that  of 
scarlet  fever.  If  the  case  is  enteric  fever,  the  abdominal  symp- 
toms point  to  that  cause  of  the  rash;  while,  on  the  other  hand,  if 
it  is  scarlet  fever,  the  throat  symptoms  will  point  to  this  malady. 
In  those  cases  in  which  marked  pharyngeal  irritation  ushers  in 
typhoid  fever,  however,  the  diagnosis  may  be  very  difficult. 
Recently  a  patient  under  our  care  suffered  from  a  mild  attack  of 
typhoid  fever  lasting  seventeen  days,  and  ten  days  later  was  sud- 
denly seized  by  a  high  temperature  and  general  illness.     When 


,S7aA^  IN  WET  J.  I)Kvi<:t/)P[':d  STAaE  of  disease       175 

he  came  iiiidcr  ohscrvulion  a  scfond  \\\\u-  he  IkkI  ;i  jHofiise  rasli 
over  Ill's  body;  liis  eyes  were  injeelcd,  ;iiid  on  I  Ik-  iniieous  riierri- 
brane  of  the  palate  and  on  tlu;  lool"  of  tlx-  moiidj  diere  was  a 
profuse  punetated  eruption.  'J'Ik;  siibsecjucnf  course  of  (his  case 
showed  that  he  was  sufferinjr  from  ;i  nu'ld  typlioid  relapse.* 

The  rash  of  typhoid  fever  is  not  a  (constant  symptom,  and  may 
appear  on  the  arms  and  even  the  hands,  instead  of  on  the  trunk. 
In  199  cases  under  Osier,  l.'i.l  per  cent.  h;id  no  rash. 

Abnormal  eruptions  occurriuf^  in  typhoid  fever  in  children  were 
described  as  long  ago  as  1839  by  Taupin,^  who  tells  us  that  a 
uniform  erythema  resembling  scarlet  fever  may  be  present,  but 
is  not  followed  by  desquamation  or  cedema.  He  also  says'  that 
he  has  never  seen  a  vesicular  rash  such  as  has  been  described 
before  his  time  by  Prosper  Dor. 

The  other  forms  of  aberrant  rash  in  typhoid  fever  are  usually 
developed  later  than  the  tenth  day.  They  consist  in  small  hemor- 
rhagic exudations  or  petechise.  In  other  cases  they  may  be  as  large 
as  a  silver  half-dollar,  and  do  not  disappear  on  pressure.  It 
is  as  if  the  rash  developed  and  then  hemorrhage  took  place  into 
the  spot. 

Another  form  of  skin  manifestation  in  typhoid  fever  is  the 
tache  bleudtre.  They  were  first  described  as  occurritt^  in  typhoid 
fever  in  1837  by  Piedagnel.  We  are  confident  that  w^e  have  seen 
them  in  cases  which  were  not  infected  by  lice,  but  Hewetson* 
speaks  as  follows  in  respect  to  this  question: 

"There  exists  a  considerable  difference  of  opinion  as  to  the 
diagnostic  value  of  these  spots.  JMany  writers,  particularly  the 
English,  believe  that  they  are  often  seen  in  the  early  stages  of 
typhoid  fever,  and  have  laid  some  stress  upon  their  presence, 
although  they  admit  their  occasional  occurrence  with  pediculi. 
Other  observers,  especially  the  French,  claim  that  they  do  not 
exist  unless  pediculi,  and  more  particularly  the  pediculi  pubis,  are 
present;  that  when  the  spots  exist  the  pediculi  or  their  nits  can 

1  For  a  discussion  of  the  various  fornix  of  roseolous  rash  see  Hare's  Text -book  of  Prac- 
tical Diagnosis,  sixth  edition.     See  also  later  chapter  on  Scarlet  Fever  and  Measles. 

-  Taupin     Journal  des  Connaissances  M<?d.  Chirurgicale,  1S39. 

'  Taupin.  This  essay  is  an  exhaustive  and  excellent  account  of  the  disease  as  seen  early 
in  the  last  centurJ^ 

^  Hewetson.    Johns  Hopkins  Hospital  Bulletin,  vol.  v. 


17G  WELL-DEVELOPED  STAGE  OF  THE  DISEASE 

be  found  if  looked  for  carefully.  Our  experience  leads  us  to 
believe  that  the  latter  view  is  correct,  as  in  the  cases  of  typhoid 
fever  in  Avhich  the  peliomata  were  present,  we  were  able  in  each 
instance  to  find  either  the  pediculi  or  their  nits.  There  have  been 
several  cases  other  than  typhoid  fever  in  which  these  grayish- 
blue  spots  were  found,  but  always  associated  with  pediculi.  There 
are  at  present  two  cases  in  the  wards,  one  with  catarrhal  jaundice 
and  another  admitted  for  chronic  bronchitis  and  emphysema.  In 
neither  case  is  there  any  elevation  of  temperature,  but  in  both 
there  are  numerous  steel-gray  spots  scattered  over  the  abdomen, 
thorax,  inner  sides  of  the  thighs,  and  here  and  there  on  the  arms 
and  legs.  In  both  the  pediculi  are  numerous,  particularly  over 
the  pubes,  and  also  in  the  hair  over  the  various  sites  where  the 
iache  hleudtre  are  present.  In  both  cases  they  are  quite  plenti- 
ful in  the  axilhie,  but  in  neither  have  they  been  found  on  the  hairs 
of  the  head  or  face.  They  do  not  appear  to  have  caused  much 
irritation;  neither  patient  complained  of  itching,  nor  are  there 
marks  of  much  scratching.  Indeed,  I  find  that  one  patient,  for- 
merly an  Austrian  soldier,  is  quite  indignant  at  the  removal  of 
both  hair  and  pediculi.  He  tells  me  that  they  are  considered  as 
brino-inff  luck  to  the  bearer,  and  each  sells  for  from  five  to  ten 
kreuzers  among  the  soldiers.  They  have  been  carefully  carried 
by  him  for  ten  years." 

Sudamina,  due  to  the  retention  of  sweat  drops  beneath  the  epi- 
thelial layer  of  the  skin,  are  met  with  in  cases  in  which  sweating 
has  taken  place,  during  high  fever,  as  a  rule.  It  is  claimed  by 
Baradat  de  Lacaze  that  sudamina  may  possess  definite  prognostic 
value.  In  quite  an  exhaustive  paper^  he  concludes  that  the  ap- 
pearance of  sudamina  at  the  beginning  of  the  second  week  of 
typhoid  fever  are  of  little  or  no  value  in  fixing  the  prognosis;  but, 
on  the  other  hand,  their  appearance  again  in  the  second  week,  or  in 
the  period  of  ambiguity,  nearly  always  indicates  the  entrance  into 
active  convalescence.  De  Lacaze  believes  its  development  at  this 
time  means  a  crisis  in  the  course  of  the  affection. 

Urticaria  may  occur,  and  there  may  also  be  a  peculiar  mottling 
of  the  skin  due  to  local  capillary  atony. 

'  De  Lacaze.    Revue  de  Mddecine,  1887,  p.  275. 


SKIN  IN  W/'JLL  D/'JVf'JLOrhl)  STAdl'l  OF  1)1  SIC  ASF         177 

The  .so-called  tache  crircbrale  is  a  red  line  witli  whiff;  hoifhr 
produced  in  this  and  oilier  iev(;rs  \)y  driivviti<^  llic  fin^ffr  n;iil  o\(r 
the  skin  of  the  patient. 

Deeper  lesions  of  the  skin  ilian  (liosc  jiisl.  discussed  sometimes 
complicate  typhoid  fever.  Tliey  consist  in  Ix^ils  and  fjirhnncles, 
and  are  due  to  infection  of  the  follicles  hy  })yoir(;nic  or;^ani.sms  of 
the  ordinary  forms  or  by  the  specific  organism  of  enteric  fever. 
They  are  usually  met  with  in  cases  which  are  severe  and  character- 
ized by  great  lowering  of  the  vitality,  and  are  probably  more  often 
met  with  in  convalescence  than  in  the  acute  period  of  the  fever. 
One  of  us  suffered  from  a  carbuncle  on  the  back,  which  came  on 
about  the  twelfth  day  of  an  attack  and  persisted  during  a  relapse 
and  well  into  the  second  convalescence. 

Bed-sores  usually  develop  only  in  those  cases  which  are  pro- 
foundly ill,  or  are  not  well  nursed,  in  the  sense  that  they  lie  in 
bedding  which  is  soiled  by  discharges.  Since  the  use  of  the  cold 
bath  or  sponging  they  are  rarely  met  with,  because  this  method 
of  treatment  causes  the  patient  to  change  his  posture  fre(|uently, 
keeps  him  clean,  and  restores  the  local  circulation  in  the  skin 
where  it  is  anaemic  or  congested.  The  most  common  seat  for  this 
lesion  to  occur  is  over  the  sacrum. 

Superficial  gangrene  of  the  skin  is  very  rare,  but  was  met  with 
very  early  in  the  history  of  the  recognized  disease.  Thus,  Taupin^ 
mentions  a  case  of  sloughing  of  the  thighs,  sacral  region,  knees, 
elbows,  and  of  the  face,  in  a  child  with  typhoid  fever.  The  skin 
became  violaceous  in  appearance  and  mortified,  and  this  was 
accompanied  by  increase  in  the  delirium.  In  one  case  under  our 
care  some  time  since  there  developed  on  the  inside  of  the  left  calf  of 
a  girl,  aged  nineteen  years,  an  area  of  gangrene.  She  had  suffered 
some  days  before  from  a  series  of  profuse  hemorrhages,  for  which 
hypodermoclysis  had  to  be  used  to  save  life.  None  of  the  areas 
of  injection  sloughed,  and  no  injection  was  given  near  this  spot, 
which  broke  down  (Fig.  21).  Two  brown  ecchymotic  spots  formed 
on  the  heels  where  they  rested  on  the  bed,  but  did  not  slough. 
The  separation  of  the  slough  was  accompanied  by  loss  of  power 
and  sensation  in  the  anterior  part  of  the  leg,  evidently  from  periph- 

1  Taupin.    Journal  des  Connaissances  Med  Chirurgicale,  1S39,  Xo.  7. 

12 


178 


WELL-DEVELOPED  STAGE  OF  THE  DL'^EASE 


eral  neuritis/  (For  further  discussion  of  this  subject,  see  the 
circukition  in  the  developed  stage  of  typhoid  fever,  and  nervous 
lesions  in  convalescence.) 

Herpes  labialis  is  thought  by  some  to  excliuk'  tlie  diagnosis 
of  enteric  fever  if  it  be  present.  Osier  reports  20  cases  in  ^^•hich 
it  occurred,'  and  the  writer  has  seen  one  during  the  present 
year. 

That  herpes  occurs  quite  frequently  in  some  epidemics  of 
typhoid  fever  is  shown  by  the  statement  of  Zinn,^  who  states  that 
it  was  met  with  in  5  per  cent,  of  190  cases  in  the  hospital  at 
Nuremberg. 

Fig.  21 


Superficial  gangrene  of  the  skin  complicating  tyiihoid  fever  (author's  wards). 

A  very  extraordinary  series  of  10  cases  of  gangrene  of  the  skin 
has  been  recorded  by  Stahl,  which  occurred  in  soldiers  in  St. 
Agnes'  Hospital  in  1S98.  He  has  kindly  permitted  me  to  use 
the  accompanying  figures.     (See  Plates  I  and  H.) 

Jacobi^  saw,  in  a  boy,  aged  nine  years,  during  typhoid  fever  an 
extensive  gangrenous  condition  of  the  skin  of  the  abdomen  from 
which  recovery  occurred.  Abt^  has  also  published  a  similar  case 
W'hich  occurred  in  a  child  of  twenty-one  months.  This  child  was 
first  noticed  to  have  furuncles.     After  two  weeks'  illness  papules 


1  For  an  interesting  paper  on  infectious  disseminated  gangrene  of  the  skin,  see  Caillaud  in 
the  Re\'ue  Mensuelle  des  Maladies  de  TEnfance,  1897,  p.  1. 
-  Osier.    Johns  Hopkins  Hospital  Reports,  1901,  vol.  v. 
'  Zinn.    Miinchener  med.  Wochenschrift. 
■•  Jacobi.    Archives  of  Pediatrics,  December  15,  1899. 
*  Abt.    Journal  American  Medical  Association,  1901. 


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HKiN  IN  WKfj.  i)i':\'i<:[/n'i':i)  sta(;/':  of  dlsfasf      J79 

<)('CiliT('<l  iipoii  (lie  skill  of  (lie  alxloiiicii ;  these  Ijccaiiic  pii.sliilar, 
and  a,  sliorl,  time  later  tlie  skin  (x'cainc  ^aii^rcnoii.s.  McFarlarid 
has  also  r('|)()rt('(l  a,  series  of  cases  in  wliieli  ii;aii^^reiie  of  (lie  skin 
resulted  dnrino-  typiioid  fever. 

Drelil'  lias  reported  a,  ease  of  exfoliative  derma  litis  diirini^ 
typhoid  fever. 

Taupin^  states  that  he  saw  two  childreji  (Jie  in  typhoid  fever 
with  severe  erythema  nodosum,  and  that  sudamina  were  common 
in  his  experience. 

Hemorrhagic  eruptions  may  occur  in  the  course  of  tyf)hoid 
fever,  and,  as  a  rule,  they  appear  in  the  neighborhood  of  the 
joints,  when  the  exudation  may  be  small  or  quite  large. 

Nichols^  reports  four  cases  in  which  the  hemorrhagic  diathesis 
developed  on  the  thirteenth,  eighteenth,  twenty-eighth,  and  thirty- 
sixth  days  of  typhoid  fever.  Only  one  of  these  cases  died.  Very 
rarely  the  tendency  to  hemorrhagic  leakings  may  become  general 
and  result  in  haemoptysis,  hsematemesis,  and  hemorrhages  from 
the  bowels.  A  case  of  this  character  is  recorded  in  the  North 
Carolina  Medical  Journal  for  September,  1890,  in  which  a  child, 
aged  ten  years,  suffered  from  this  disease.  At  the  end  of  the  fourth 
week  of  the  disease  there  was  bleeding  from  the  gums,  the  nose, 
and  blood  in  the  urine.  The  spots  appeared  first  on  the  feet  and 
legs,  later  on  the  arms,  then  on  the  trunk,  and  finally  in  the 
conjunctiva. 

In  other  cases  hemorrhages  other  than  those  just  named  took 
place.  Thus,  Hughes  and  Levy"*  report  a  case  in  which  a  man, 
after  an  ordinary  attack  of  typhoid  fever,  suffered  from  a  relapse 
ill  the  sixth  week.  Abscesses  developed  in  both  forearms  and  in 
the  left  arm.  When  an  incision  was  made  into  the  abscess  extra- 
vasations of  blood  into  the  intramuscular  aponeurotic  tissues  took 
place,  and  afterward  this  was  followed  by  manifestations  of  acute 
purpura,  as  indicated  by  pectechiae,ecchymoses,and  severe  epistaxis. 
Recovery  took  place. 

Another  abnormality  in  the  typhoid  rash  has  been  described  by 

1  Drehl.     Journal  Cutaneous  and  Genito-urinary  Diseases,  1S9S. 

-  Taiipin.    Journal  des  Connaissanees  'Mid.  Chirurgicale,  1839,  No.  7. 

3  Nichols.     Montreal  Medical  Journal,  June,  1S96. 

■•  Hughes  and  Le^-J'.    Archives  de  Medecine  et  de  Phar.  Militaires,  August,  1S92. 


180  WELI^DEV ELOPED  STAGE  OF  THE  DISEASE 

Day.*  The  erii})ti()n  \vas  on  the  chest,  abdomen,  and  btiek,  and 
occurred  in  irregular  dark  patches,  shghtly  raised,  and  disappeared 
on  pressure,  tliough  they  left  some  pigmentation  after  their  dis- 
appearance. They  were  not  petechia;.  Day  asserts  that  he  has 
met  with  ten  other  cases  of  this  character,  and,  further,  that  in 
four  of  them  intestinal  hemorrhage  was  foretold  by  their  occur- 
rence in  connection  witli  fever,  a  rapid  pulse,  and  a  clear  mind. 

Eruptive  Diseases  in  the  Course  of  Typhoid  Fever. — How 
frequently  scarlet  fever  complicates  typhoid  fever  is  a  difficult 
matter  to  decide.  INIurchison-  says  that  in  ten  years  he  saw  only 
one  case  of  scarlet  fever  which  contracted  t)'phoid  fever,  and  that 
developed  on  the  twenty-sixth  day.  On  the  other  hand,  he  cites 
several  cases  in  which  typhoid  fever  patients  suffered  later  from 
scarlet  fever.  This  was  written  in  1859.  Later  still  he  wrote^ 
that  in  the  wards  of  the  London  Fever  Hospital,  in  which  all 
fever  cases  were  treated  without  isolation,  he  had  seen  eight  cases  in 
which  the  eruption  of  the  two  diseases  existed  simultaneously. 
In  one  of  these  the  eruption  of  scarlet  fever  appeared  in  the  third 
week  of  enteric  fever,  and  in  the  other  on  the  twenty-second  day. 
Indeedj  he  goes  so  far'  as  to  assert  that  scarlet  fever  appears  to 
predispose  to  typhoid  fever. 

Sequeira^  records  two  cases  of  t^^hoid  fever  complicated  by 
scarlet  fever.  In  one  the  scarlatinal  symptoms  developed  on  the 
tenth  day,  and  in  one  five  days  after  the  enteric  rash.  Still  more 
interesting  are  the  cases  recorded  by  Griffiths."  Four  children,  all  in 
the  same  family,  were  attacked  by  both  diseases.  A  boy,  aged  eleven 
years,  on  the  sixth  day  of  scarlet  fever  developed  typhoid  fever. 
A  girl,  aged  thirteen  years,  got  scarlet  fever  three  weeks  after  her 
brother  and  developed  enteric  fever  twelve  days  later.  A  girl,  aged 
three  years,  who  had  scarlet  fever,  suffered  from  typhoid  fever  on 
the  eleventh  day,  and  a  girl,  aged  seven  years,  also  on  the  eleventh 
day  after  scarlet  fever  began.  These  cases  are  of  special  interest 
in  that  a  nearly  simultaneous  infection  with  both  fevers  must  have 
occurred. 

1  Day.    Dublin  Journal  of  Medical  Sciences,  March,  1896. 

'  Murchison.    British  and  Foreign  Medico-ChirurKical  Review,  July,  1859,  p.  194. 

5  Murchison.    The  Continued  Fevers  of  Great  Britain,  third  edition,  p  586. 

*  Loc  cit.,  p.  455.  '  Sequeira.    Brit.  Med.  Jour.,  1891,  i,  849. 

«  Griffiths.    Lancet,  1893,  ii,  1307. 


ERUPTfV/'J  DfS/'JASl'IS  IN  Tfl/'J  COUIiSH  Oh'  TYI'IIOII)  FEVKU.     181 

Caiger*  riict  willi  Ivvo  cuscs  of  ,sr;irlcl,  fever  roinfidrnl.  wiUi 
ty[)li()i(l  f(>vcr,  iU)(l  Payne"  re[)()rt,s  one  .sue!i  ea.s(;. 

Ciirniichjiel'  also  has  reported  the  case  of  a  hoy,  aged  six  years, 
who,  after  sufl'ering  from  scarlet  fever  and  going  on  to  the  stage  of 
desquamation,  continued  f(l)rile  from  oncoming  ty{)hoid  fever,  and 
Cosgrove''  records  five  eases  of  concurrent  scarlet  and  typhoid 
fever  seen  in  the  (Jork  Street  Hospital.  In  four  of  these  the  incuba- 
tion stages  were  concurrent,  the  scarlet  fever  heing  secondary, 
so  that  the  onset  was  simultaneous.  This  same  author  tells 
us  that  instead  of  increasing  the  severity  of  the  typhoid,  the  scarlet 
fever  seemed  to  abort  it,  though  the  cases  were  fairly  severely  ill. 
Coombs''  reports  a  case  in  which  a  boy,  aged  eleven  years,  who  had 
scarlet  fever,  his  family  having  typhoid  fever,  was  seized  on  the 
seventeenth  day  of  his  illness  by  typhoid  fever.  Gabe"  reports 
another  case. 

The  danger  of  confusing  adventitious  scarlatiniform  rash  in 
typhoid  fever  with  that  of  scarlet  fever  was  emphasized  by  ^lur- 
chison  and  by  Moore^  and  Jenner,^  and  more  recently  by  Bassett." 
Moore  has  also  seen  desquamation  take  place  in  this  form  of  rash.^** 

The  case  of  a  child,  aged  eleven  and  a  half  years,  has  been  reported 
by  Chrystie,^^  which  is  of  particular  interest,  because  of  the  fact 
that  measles  developed  during  the  attack  of  typhoid  fever.  Death 
occurred  in  convulsions.  A  similarly  constituted  attack  of  typhoid 
fever  and  measles  is  also  recorded  by  Matiegka.^"  The  symptoms 
of  enteric  fever  were  well  marked  on  the  fourteenth  day  of  the 
disease,  when  the  eruption  of  measles  appeared  over  the  face  and 
body.  A  similar  case  has  been  reported  by  Ringer,^^  in  a  girl,  aged 
ten  years,  and  Ringwood^*  records  a  case  in  which  the  child  had 
measles  and  enteric  fever  simultaneously,  followed  by  a  severe 
attack  of  diphtheria,  scarlet  fever,  and  chickenpox,  all  in  the 
space  of  seven  weeks. 

1  Caiger.    Lancet,  1S94,  i,  1137.  ^  p^yne.    Ibid.  ^  Carmichael.    Ibid.,  p.  246 

*  Cosgrove.    British  Medical  Journal,  January  16,  1897,  p.  29. 

6  Coombs.     Ibid.,  February  27,  1897.  «  Gabe.    Loc.  cit.,  April  3,  1897,  p.  848. 

'  Moore  Accidental  Rashes  in  Typhoid  Fever,  Transactions  Royal  .Academy  of  Medicine 
in  Ireland.  1889,  vii,  10,  and  Eruptive  and  Continued  Fevers,  1892,  p.  371. 

8  Jenner.    Fevers,  1893.  ^  Bassett.    British  Medical  Journal,  April  10,  1897. 

1*  Moore.    Loc.  cit.,  January  16,  1897. 

11  Chrystie.     University  Medical  Magazine,  December,  1888. 

'^  Matiegka.    Prager  med.  Wochenschrift,  September  25,  1889. 

13  Ringer.    London  Lancet,  June  30,  1889.  "  Ringwood.    Loc.  cit.,  July  7,  1889. 


CHAPTER   IV. 

THE  COMPLICATIONS  OF  THE  PERIOD  OF  CONVALESCENCE. 

Temperature,  Recrudescence,  and  Relapse. — Recrudescence 
sifijnifies  a  teniporarv  rise  of  fever  lasting  for  a  few  days  or  a  few 
hours,  and  is  usually  due  to  the  ingestion  of  improper  food,  to  ner- 
vous excitement,  or,  more  rarely,  it  seems  to  arise  from  al)sor])tion 
from  the  intestinal  canal  of  some  toxic  material  which  temporarily 
upsets  the  balance  of  heat  production  and  heat  dissipation.  In 
several  instances  the  senior  author  has  seen  full  doses  of  strych- 
nine, given  as  a  circulatory  stimulant,  produce  repeated  exacerba- 
tions of  the  normal  temperature  to  the  extent  of  2°  or  3°  by 
reason  of  its  irritant  effect  on  the  nervous  system. 

As  has  already  been  stated,  a  true  relapse  cannot  be  said  to  have 
taken  place  until  the  physician  is  assured  by  another  crop  of  rose 
rash,  enlargement  of  the  spleen,  coated  tongue,  and  persistent  fever 
that  a  second  attack  is  upon  the  patient.  If  these  distinct  signs  of 
another  infection  are  present,  then  the  diagnosis  is  as  complete 
as  it  can  be  made  without  the  conclusive  proof  of  a  positive  blood 
culture,  which  can  only  be  made  by  a  competent  bacteriologist. 
An  important  confirmatory  sign  of  the  presence  of  a  relapse  during 
convalescence  from  typhoid  fever  is  the  reappearance  of  the  diazo 
reaction  when  the  urine  is  tested. 

Relapses  occur  in  a  fairly  large  percentage  of  cases,  and  seem 
particularly  prone  to  take  place  in  those  in  whom  the  primary 
attack  of  the  malady  has  been  mild.  Indeed,  the  milder  the 
attack,  the  more  likelihood  is  there  of  relapse.  Further  than  this, 
the  use  of  the  cold  bath  in  treating  the  disease  increases  the  fre- 
quency of  relapse  quite  distinctly.  What  the  average  frequency 
of  this  unfortunate  occurrence  is  is  difficult  to  determine,  because 
different  epidemics  differ  greatly  in  the  results  they  produce,  so 
that  in  one  epidemic  relapses  will  occur  with  great  constancy,  and 
in  another  almost  none  will  occur.     Ord^  believes  that  relapses 

'  Ord.    Transactions  of  Association  of  American  Physicians,  1888,  vol.  iii. 


TEMPERATURE,   RECRUDESCEiW(JE,   AND   RELARSE        IS?, 

arc  Miorc  IVctjiicnl  in  cmscs  wifli  coiistipiilion  llinii  in  those  with 
diarrli(X';i,  and  (hat  roinf'o(;(ion  from  within  cxphiin.s  their  fre- 
quency in  these  instances.  In  our  experience,  rehipses  liave  br-en 
much  more  common  in  constipated  cases. 

Warfield,  in  reporting  an  instance  of  typhoid  fever  with  tfiree 
rehipscs,  has  called  attention  to  the  theory,  as  to  the  causation  of 
rehipse,  advocated  l>y  Stewart,  which  he  has  based  upon  the  autopsy 
findings  in  60  cases  which  (\'hh\  (hnint^^  rehipse  in  typhoir]  fever. 
Stewart  found  tliiit  SO  jx-r  cent,  of  these  cases  revealed  recent  lesions 
in  the  large  intestine,  while  the  small  intestine  contained  lesions  in 
the  process  of  healing.  These  findings  were  compared  by  Stewart 
with  the  results  of  the  examination  of  cases  dying  in  the  primary 
attack  of  fever  in  which  the  author  found  no  lesion  in  the  large 
intestine  in  75  per  cent,  of  cases.  From  these  findings  Stewart 
concluded  that  relapse  in  typhoid  fever  was  due  to  the  presence  of 
lesions  in  the  large  intestine,  a  method  of  reasoning  which  is  entirely 
fallacious  and  has  no  evidence  to  support  it.  A  much  more 
rational  view  would  be  that  the  continuance  of  the  pathological 
process  in  the  relapse  gave  time  for  greater  destructive  processes 
to  take  place  in  tissues  in  which  lesions  had  not  become  severe 
when  the  relapse  occurred.  That  Stewart's  views  are  incorrect 
has  been  proved  by  the  investigations  of  Warfield,  who  cites  the 
findings  at  autopsy  in  cases  dying  during  relapse  at  the  Johns 
Hopkins  Hospital,  in  two-thirds  of  which  no  lesion  was  found  in 
the  large  intestine. 

A  much  more  probable  theory  has  been  advanced  by  Durham 
as  to  the  cause  of  relapse,  who  suggests  that  when  ^eco^'ery  takes 
place  the  intestine  has  developed  enough  protective  substances  to 
enable  it  to  withstand  the  disease,  whereas  when  relapse  occurs  the 
quantity  and  activity  of  these  antibodies  is  sufficient  to  prevent 
death,  but  not  sufficient  to  prevent  relapse. 

In  regard  to  the  frequency  of  relapse  it  is  interesting  to  note  that 
no  less  an  observer  than  Murchison  places  the  average  percentage 
at  3  per  cent.;  Gerhardt,  in  4000  cases,  6.3  per  cent.;  Griesinger 
puts  it  at  6  per  cent.,  and  Strtimpel  at  4  to  16  per  cent.  Berg^  met 
with  relapse  in  12  per  cent,  of  1626  cases  in  Curschmann's  clinic  from 

1  Berg.    Deutsche  Arcliiv  fiir  klin.  ^led.,  1S95. 


184  cn}fPLiCATinxs  nrnixa  coxvalescence 

1880  to  1892.  Eichhoivst,  in  606  cases  in  Zuricli,  found  relapses 
in  4.2  per  cent.  Zennetz/  in  384  cases  of  typlioid  fever,  found  47 
relapses,  of  Avhich  17  were  entirely  uncomplicated.  In  the  Maid- 
stone epidemic  relapses  occurred  in  16  per  cent.,  and  were  more 
common  in  females  than  in  males.  Schmidt"  found  49  cases  of 
relapse  in  561  cases  of  fever  treated  in  Wagner's  clinic  from 
1882  to  1886,  or,  if  doubtful  cases  be  excluded,  38  relapses,  or  a 
percentage  of  6.8,  Aviiicli  practically  agrees  with  the  percentage 
obtained  by  Gerhardt,  who,  in  the  study  of  4000  cases  selected 
from  various  epidemics,  obtained  a  percentage  of  6.3,  while 
Heman's  percentage  was  6.5,  and  Steinthal's  7.5.  Liebermeister 
says:  "In  Basel,  before  the  introduction  of  this  (the  bath)  treat- 
ment, 861  typhoid  fever  patients  gave  us  64  relapses,  or  7.4  per 
cent.,  two  of  which  were  fatal;  after  the  introduction  of  this 
treatment,  882  typhoid  fever  patients  gave  86  relapses,  or  9.8  per 
cent.,  ten  of  which  proved  fatal.  It  appears,  therefore,  that  the 
proportion  of  relapses  and  the  number  of  deaths  are  both  actually 
increased  under  the  use  of  cold  water."  And  discussing  the  prob- 
able bearing  of  these  results,  he  adds:  "At  present  the  probability 
certainly  seems  to  be  in  favor  of  the  affirmative  of  the  question 
(Does  bathing  increase  the  frequency  of  relapses  ?)  the  more  so  as 
it  appears  that  the  frequency  of  relapses  is  greater  in  proportion 
as  the  antipyretic  treatment  has  been  the  more  systematically  em- 
ployed." Biermer  has  also  found  relapses  more  frequent  since 
the  introduction  of  cold  baths.  Osier  reports  1500  cases  of 
typhoid  fever,  with  173  relapses,  or  11.4  per  cent.,  and  states  that 
he  met  with  14  cases  of  relapse  in  100  patients  that  were  bathed, 
or  8.7  per  cent.,  but  mentions  five  other  cases  of  doubtful  relapse 
which  raises  the  percentage,  while  the  limited  number  of  bathed 
cases  as  compared  to  the  large  number  of  unbathed  cases  renders 
a  comparison  of  the  percentages  of  the  relapses  of  limited  value. 
Shattuck  met  with  21  in  129  cases,  or  16  per  cent.,  and  eleven 
occurred  before  primary  fever  ceased.  Wilson  tells  us  that  it 
occurred  in  11.3  per  cent,  of  his  cases;  Shattuck,  16  per  cent.; 
Immermann,  15  to  18  per  cent. ;  Baumler,  1 1  per  cent. ;  and  Jaccoud^ 

1  Zennetz.    Wiener  med.  Wochenschrift,  September  21,  1S94. 
*  Schmidt.    Archiv  fiir  klin  Medicin,  Band  xliii,  Heft  3. 


TEMPi<:iiATUUi<:,  i{i<:(;i{UI)i<:s(!I':n(:e,  and  rklai'si<:      ],s5 

9  per  ccTii,.,  varyinji;  rrom  7  (o  IT)  [xr  fcul.  A I  I  Ik-  rtcshyterian 
Hospital  in  New  York,  (iilman  'riiompsoii  fourn]  Uir-  iflajj.sf-.s  in 
193  bathed  cases  to  be  l.'J.r)  per  txiit.,  wliidi  is  2  per  ecnt.  Iiiglier 
than  284  cases  treated  by  all  methods  during  the  same  time. 

There  are  certain  peculiarities  in  the  course  of  a  relapse  as  to 
the  f(>vcr,  tlu;  circulation,  and  the  other  fimctions  which  deserve 
attention.  The  fever  usually  rises  more  abruptly  than  in  the  origi- 
nal attack,  and  then  speedily  loses  its  high  grade  and  becomes 
more  moderate.  Often  it  is  more  irregular  and  has  greater  remis- 
sions than  the  primary  fever.  Whether  it  be  high  or  low,  its  course 
is  usually  shorter  than  the  original  period  if  that  has  been  of  stand- 
ard length  or  longer,  but  if  the  first  attack  has  been  quite  short 
the  relapse  is  not  infrequently  much  longer.  Thus,  in  one  case 
recently  seen  by  us,  the  primary  fever  lasted  twelve  days,  and 
that  of  relapse  nineteen  days.  Flint  is  the  only  author  of  note 
who  thinks  the  relapse  is  generally  worse  than  the  primary 
attack. 

It  is  interesting  to  note  that  in  Liebermeister's  cases,  out  of  111 
cases  of  simple  relapse  the  fever  was  longer  in  duration  than  in 
the  first  attack  in  37,  shorter  in  68,  and  of  the  same  length  in  2. 
In  29  of  the  cases  the  primary  attack  was  mild,  and  in  82  severe, 
but  the  relapses  were  mild  in  47  and  severe  in  64,  and  7  of  these 
died  in  the  relapse. 

An  important  point  to  determine  is  the  danger  of  relapse  as  to 
both  complications  and  mortality.  Here,  again,  the  variation  in  the 
severity  of  the  symptoms  in  relapse  is  so  great  that  it  is  almost 
impossible  to  reach  definite  results.  It  is  certain  that  relapses  are 
not  to  be  regarded  lightly,  and  that  they  should  be  recognized 
with  a  certain  degree  of  anxiety,  even  when  they  appear  to  be 
mild  in  type,  because  the  exhausted  state  of  the  patient  renders 
him  more  prone  to  complications  and  less  able  to  withstand  the 
general  toxaemia  of  the  new  infection. 

This  is  well  showai  by  the  statistics  at  Basel,  when  out  of  115 
relapses  hemorrhage  from  the  bowel  occurred  four  times,  perfora- 
tion twice,  thrombosis  once,  pulmonary  consolidation  nine  times, 
nose-bleed  seven  times,  bed-sores  four  times,  abscesses  five  times, 
and  petechise  three  times. 


186  COMPLICATIONS  DURING  CONVALESCENCE 

To  quote  Liebermeister  again:  "If  wc  take  the  reports  of  the 
years  1S69,  1870,  and  1872  at  Basel,  we  find  among  467  t}-phoid 
fever  patients  systematically  treated  with  cold  baths,  33  deatlis 
and  55  relapses,  6  of  which  were  fatal;  the  frequency  of  relapses, 
therefore,  counting  only  those  patients  wlio  had  survived  the  first 
attack,  was  in  the  proportion  of  12.5  per  cent.,  as  against  9  per 
cent,  before  baths  were  used.  The  higher  rate  of  mortality  among 
the  relapses  is  of  so  much  greater  import,  in  view  of  the  fact  that 
the  relapses,  too,  were  treated  antipyretically,  which  ought  rather 
to  have  ffiven  us  a  lower  death-rate." 

The  time  at  which  relapses  occur  is  of  interest.  Usually  they 
take  place  after  the  temperature  has  been  normal  several  days,  and 
in  some  instances  much  later  than  this.  More  rarely  we  meet 
with  what  has  been  well  called  "intercurrent  relapse,"  in  which 
the  renewed  activity  of  febrile  movement  and  exacerbations  of  all 
the  symptoms  show  that  a  second  infection  has  been  superimposed 
on  the  first. 

In  children,  relapses  are,  as  a  rule,  more  rarely  met  with  than 
in  adults,  although  this  accident  varies  greatly  in  frequency. 
Among  the  older  writers  we  find  Rilliet  and  Barthez,  who  saw 
only  three  relapses  in  111  patients,  while,  on  the  other  hand, 
Henoch  met  with  no  less  than  21  relapses  in  137  cases,  the  relapses 
taking  place  after  both  severe  and  mild  primary  attacks,  although 
the  mild  attacks  were  most  commonly  followed  by  this  accident. 
Taupin,  writing  in  1839,  records  two  cases  of  relapse  in  boys  of 
thirteen  and  twelve  years;  both  recovered. 

As  with  adults,  the  relapse  usually  takes  place  in  children  in 
from  three  to  ten  days  after  the  primary  fever  has  ceased,  although 
it  may  occur  in  the  course  of  the  disease  in  the  third  week,  or 
even  in  the  fifth  week.  Henoch  records  one  instance  in  which 
relapse  took  place  in  a  child  eighteen  days  after  apyrexia  had  been 
established. 

Not  only  may  a  patient  suffer  from  a  single  relapse,  but  rarely 
from  several  relapses.  Hutchinson^  has  recorded  a  case  in  which 
three  well-marked  relapses  occurred,  and  Anders-  has  done  so  also. 

'  Hutchinson.    American  System  of  Medicine,  Pepper,  vol  i,  p.  303. 
2  Anders.    Medical  and  Surgical  Reporter,  July,  1882,  p.  66. 


TEMPEIiATUlU':,   U.I'XIfa/DMSC'/'JNC'/'J,   ANT)   li ELAPSE        ]S7 

The  chart  (sec  l^'i<;.s  22,  2?>)  shows  (wo  rr-hipses. 

In  a  case  at  i\\v  Pciiiisylvjiiiiii,  II()S|>i(;iI  in  1 004,  r|ijf)tcfl  })y  Dslfr 
in  Ill's  Practice  of  Medicine,  the  disease  lastecJ  elev(;ii  months  and 
four  days,  during  which  time  there  were  six  relapses. 

Multiple  relapses  have  also  been  rvvttvAi-t]  \)\  .lohn^lon.'  In  one 
case  a  patient,  aged  thirty-nine  years,  had  twcj  rehijjscs,  Jind  was 
in  the  hospital  eighty-one  days  A  second  case  had  two  relapses 
A  third  case  after  a  primary  attack  had  two  relaf)ses,  ;ind  tlie  f>atient 
was  in  tlie  hospital  107  days. 

A  case  of  typhoid  fever  is  recorded  by  Carslaw,''  which  sulicred 
from  four  relapses  before  ultimate  recovery;  and  we  have  had 
patients  under  our  care  who  suffered  three  relapses.  Care  must 
be  observed,  however,  that  all  cases  of  returning  pyrexia,  after 
typhoid  fever  has  run  its  course,  are  not  considered  relapses  until 
the  possibility  of  infection  of  another  type  is  excluded.  Often  the 
fever  is  due  to  some  suppurative  process  caused  by  one  of  the 
pyogenic  bacteria  or  to  a  general  bacteremia  due  to  other  organs 
than  the  typhoid  bacillus. 

Rigors  of  considerable  severity  may  occur  during  convalescence 
from  typhoid  fever  without  possessing  any  great  significance. 
This  is  shown  in  the  chart  on  page  188,  and  also  in  that  on  page 
190  (Fig.  24).  Osier  reports  two  cases  of  chills  without  any  distinct 
apparent  cause  in  the  later  weeks  of  typhoid  fever.  In  both  these 
cases  the  chills  were  followed  by  hyperpyrexia. 

Similar  cases  are  recorded  by  Herringham,  Thus,  he  records 
an  instance  in  which  after  a  mild  attack  of  fever  a  rigor  occurred 
during  the  post-febrile  period  after  an  enema;  another  case  in 
wdiich  there  were  several  attacks  of  pyrexia  and  one  rigor  during 
this  time,  and  still  a  third,  in  which  recurrent  collapse  appeared 
during  lysis,  and  rigors  in  the  postfebrile  period  without  any  dis- 
coverable cause.  He  believes  that  ague  can  be  excluded  in  all  of 
his  cases.  Herrineham  also  advances  the  view  that  in  these  cases 
the  heat  mechanism  of  the  body  is  so  easily  upset  that  very  slight 
causes  provoke  febrile  movement.  We  think  this  view  unlikely, 
and  believe  that  such  sudden  rigors  with  fever  are  due  to  the 

1  Johnston.     Medical  Chronicle,  May,  1892. 
^  Carslavr.     London  Lancet,  July  19,  1891. 


18S 


COMPLICATIOXS  DUIilXG  COXVALESCENCE 


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190 


COMPLICATIOXS  DURIXG  COXVALESCENCE 


entrance  into  the  Mood,  or  lymph  stream,  of  some  pathogenic 
microorganism  previously  imprisoned  in  the  gall-bladder,  in  the 
kidney,  in  some  of  the  thoracic  or  abdominal  lymph  nodes,  or  in 
the  floor  of  a  healing  ulcer.  If  the  new  invasion  is  virulent  the 
patient  succumbs  to  a  post-typhoid  bacteremia. 


Fig.  24 


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Case  of  typhoid  fever  in  which,  according  to  the  patient's  story,  lie  liad  been  sick  only 
three  days,  but  in  which  the  disease  ended  by  a  rapid  fall  in  lysis,  followed  by  a  severe  rigor 
and  rise  of  temperature.  The  Widal  test  was  positive,  and  the  rash  and  enlarged  spleen  were 
present. 


Some  years  ago  the  late  J.  M.  Da  Costa  pointed  out  that  during 
convalescence  from  typhoid  fever  a  persistent  moderate  fever  may 
develop,  which  is  cured  by  getting  the  patient  out  of  bed.  Shattuck 
also  speaks  of  such  caaes.     We  have  had  under  our  care  several 


RESPfUATORY   AFFECrrONS  IN  CONVALFSCFNT  STAr;/-:      \')\ 

instances  of  lliis  cliarac^tor.  Tlic  [^.'-tlin^^-  up  ()u<.'lii  noi  lo  l,c  i]i;i(lo 
nntil  If,  is  (>vi(lcnl,  (Jiiil  (lie  IV-vcr  is  simply  ;i,  "hcd  lc\cr"  jiud  noi  a 
r('l;i|)S(". 

Respiratory  Affections  in  the  Convalescent  Stage  of  the 
Disease. — Aside  from  tlio  laryngeal  (see  e;itli<r  ;iimI  later  pagesj 
and  other  respiratory  difficulties  met  with  in  llic  ;iftiv(;  stage  of 
the  disease,  and  already  mentioned,  tliere  arc  no  otlicrs  to  he 
considered  at  this  point  save  pneumotlioriix,  pnliiioniiiy  abscess, 
gangrene,  and  tuberculosis.  The  latter  coiiditioii  is  discussed  in 
a  later  chapter  dealing  with  the  diseases  which  resemble  enteric 
fever. 

The  development  of  pneumothorax  during  typhoid  fever  is  an 
extremely  rare  affection.     Hale  White  has  reported  two  such  cases. 

Abscess  and  gangi-ene  of  the  lung  are  rare  sequences  of  enteric 
fever.  They  arise  from  one  of  two  causes:  either  they  are  due  to 
septic  matter  which  has  passed  into  the  bronchial  tubes  during  the 
stage  of  stupor,  or  to  septic  emboli  which  first  cause  consolidation 
and  then  tissue  breakdown.  Griesinger  met  with  gangrene  of  the 
lung  in  7  cases  out  of  118  post  mortems,  and  Liebermeister  found 
14  cases  in  230  autopsies  of  typhoid  fever  patients.  Out  of 
2000  cases  at  Munich,  there  were  40  cases  of  garrgrene  and  14 
cases  of  abscess  of  the  lung. 

Robinson  has  issued  an  interesting  report  upon  the  pulmonary 
complications  during  typhoid  fever  in  a  large  series  of  cases  at  the 
Pennsylvania  Hospital.  In  one  case  of  abscess  of  the  lung  a  pure 
culture  of  typhoid  bacilli  were  obtained  from  the  abscess  cavity  at 
autopsy.  In  another  interesting  case,  Robinson^  was  able  to  prove 
that  both  the  Bacillus  typhosus  and  the  pneumococcus  were  present 
in  the  circulating  blood.  This  combination  had  previously  been 
observed  by  Busquet"  in  1902. 

Miller^  has  reported  a  case  of  gangrene  of  the  lung  and  empyema 
in  a  child,  aged  six  years,  during  an  attack  of  tv'phoid  fever. 

The  question  as  to  whether  typhoid  fever  predisposes  the  patient 
to  infection  by  the  bacillus  of  tuberculosis  is  one  of  great  interest. 
Cases  convalescing  from  typhoid  fever  are  sometimes  met  with  in 

1  Robinson.     Proceedings  of  Pathological  Society,  1905,  No   6. 

=  Busquet.    Re^-ue  de  M^d.,  1902.  ^  Miller.    Archives  of  Pediatrics,  190S,  xxv,  .347. 


192  COMPLICATIONS  DURIXG  CO.WALESCENCE 

which  tuberculosis  is  rapidly  developiuo-.  In  some  instances  this 
is  due  to  the  fact  that  the  profound  depression  of  tlie  patient's 
vitality  renders  him  unusually  susceptible  to  any  infectious  pro- 
cess, but  more  frequently  it  is  probably  due  to  the  fact  that  the 
patient  has  had  at  some  previous  time  a  localized  tuberculous 
process  whicli  has  been  walled  off  from  the  general  system  by 
the  usual  methods  taken  by  the  body  for  its  protection.  With 
the  progress  of  a  prolonged  exhausting  malady  vital  resistance 
has  deci-eased,  and  the  local  and  comparatively  harmless  process 
rapidly  spreads  throughout  the  body. 

Curschmann^  in  his  statistics  from  Leipzig  recorded  10  instances 
of  this  complication  in  228  autopsies,  but  it  is  quite  probable  that 
the  tuberculous  lesions  antedated,  rather  than  followed,  the  attack 
of  typhoid  fever. 

Anders"  studied  the  autopsy  records  of  three  large  hospitals 
(Philadelphia,  Episcopal,  and  the  Johns  Hopkins)  to  determine 
the  relation  of  typhoid  fever  to  tuberculosis.  He  found  that  in 
249  subjects  showing  typhoid  lesions  only  23  showed  tuberculous 
lesions.  Of  these  23  eases,  in  19  the  lesion  was  observed  to  be  a 
chronic  one,  while  in  the  entire  number  there  were  but  four  acute 
cases.  These  figures  bear  out  our  belief  that  acute  phthisis 
following  typhoid  fever  is  not  a  common  occurrence.  A.  very 
common  mistake  is  to  diagnosticate  typhoid  fever  when  the  illness  is 
really  due  to  an  acute  tuberculosis,  in  which  the  slight  physical 
signs  are  either  overlooked  or  misinterpreted,  and  only  after  a 
more  or  less  prolonged  illness  is  the  tuberculosis  discovered.  We 
feel  sure  that  many  such  cases  exist,  for  nothing  is  more  common 
than  to  find  patients  suffering  from  tuberculosis  who  give  the  very 
suggestive  histories  of  having  had  two  or  more  attacks  of  what  they 
term  "typhoid  fever,"  but  which  in  reality  were  symptoms  of  an 
active  tuberculous  process  which  underwent  temporary  remis- 
sions. 

In  connection  with  this  matter  it  is  interesting  to  note  that 
Loison  and  Simonin,^  in  114  typhoid  fever  cadavers,  found  tuber- 

'  Curschmann.     Nothnagel's  System. 

2  Anders.    American  Journal  of  the  Medical  Sciences,  May,  1904. 

'  Loison  and  Simonin.  Archives  de  M^decine  et  de  Pharmacie  Militaire,  Paris,  October 
1893. 


Till':  CllidULATION  IN  (:f):\VA/J':SC'/'JNC'E  \<j:', 

culo.sis  five  limes,  and  llicy  poinl  oiil  lli;if  Ivj^hoid  fever  iii;iy 
liastcii  l.lic  (levelofHiienl  of  preilxisliii^'  (iil>ei'eiil(>ii.s  infeelif;!!.  So, 
too,  Sarda  and  Vilhird'  linve  found  llie  diseases  eo-exis(in(:. 

Zinii^  sliiles  lliiil,  ]>os(rnor(eni  e,\;iniiii;ilioii  of  llie  f;il;d  cascs 
in  190  patients  revealed  tlie  fact  that  six  of  tliern  showed  tiihr-reii- 
losis  of  the  lung  in  association  with  old  foci  at  the  apex. 

Eshner^  in  an  excellent  article  iip(;n  this  subject,  states  fliat  in 
2000  fatal  cases  of  typhoid  fever,  examined  after  death  at  Munich, 
Ilolscher  observed  108  (5.4  per  cent.)  of  tuberculosis  in  various 
situations.  In  Gruber's  series  of  710  fatal  cases  of  tyf>hoid  fever, 
22  (3.3  per  cent.)  were  complicated  by  old  lesions  of  liibeieulosis 
of  the  lungs.  Bettke,  in  1420  subjects  of  tyfjlioid  at  iiasle,  saw  23 
(1.6  per  cent.)  in  tuberculous  subjects;  while  Dopfer  recorded 
tuberculosis  in  46  (5  per  cent.)  of  927  cases  of  typhoid  fever. 

In  cases  of  typhoid  fever  which  are  convalescent  the  presence 
of  irregular  and  prolonged  febrile  movement  should  raise  a  sus- 
picion of  the  presence  of  tul)erculosis. 

The  Circulation  in  the  Latter  Stages  of  the  Disease  and  in 
Convalescence. — There  are  few,  if  any,  diseases,  which  do  not 
have  special  predilection  for  the  heart  muscle  or  its  valves,  which 
so  gravely  interfere  with  normal  circulation  as  does  typhoid  fever. 
The  length  of  the  febrile  movement  and  its  severity,  the  gravity 
of  the  toxfemia,  the  wasting  of  the  patient,  his  inability  in  certain 
cases  to  take  sufficient  nourishment,  and  the  impaired  action  of 
various  other  vital  organs  than  the  heart,  all  tend  to  produce  weak- 
ness in  the  heart  muscle  and  actual  deg■ene^ati^■e  changes  in  its 
nerve-supply  and  muscle  fibers.  As  long  ago  as  1875,  Hayem*  made 
one  of  his  characteristically  thorough  studies  concerning  the  heart 
muscle  in  typhoid  fever,  in  which  he  showed  that  a  granular 
parenchymatous  degeneration  is  present  in  many  cases,  and  that 
even  fatty  degeneration  may  be  met  with  in  prolonged  severe  cases 
associated  with  great  anaemia.  Hyaline  changes  are  not  commonly 
found,  but  a  segmenting  myocarditis,  in  which  the  intercellular 

1  Sarda  and  Villard.    Gazette  des  Hopitaux,  November  30,  1S93. 

2  Zinn.     Miinchener  lued.  Wochenschrift 

'  Eshner.    Philadelphia  Medical  Journal,  March  25,  1S99. 

*  Hayem.     Legons  Clinique  sur  les  Manifestations  Cardiaques  et   le  Fievre  T\-phoide. 
Paris,  1875. 
13 


194  COMPLICATIOXS  DURIXG  COXVALESCENCE 

cement  substance  is  softened,  may  be  present,  although  this  is,  per- 
haps, a  postmortem  change.  ]\Iany  years  ago,  Stokes  asserted  that 
the  heart  muscle  of  patients  dead  of  enteric  fever  was  so  softened 
that  if  it  were  held  upside  down  by  its  great  yesscls  the  muscle 
would  collapse  oyer  the  hand  like  a  nuishroom  overspreads  its 
stem.  In  some  cases,  on  the  other  hand,  the  heart  seems  to  escape 
almost  completely. 

As  it  is  not  the  intent  of  this  essay  to  deal  with  the  microscopic 
alterations  which  occur,  but  rather  the  objectiye  symptoms  of  the 
disease,  little  further  need  be  said  of  these  changes  themselyes, 
except  that  in  this  connection  the  researches  of  Hoffmann  are  of 
interest.  He  found,  in  an  examination  of  a  large  number  of  hearts 
in  typhoid  fever  patients,  56  instances  in  which  the  heart  muscle 
was  normal  or  little  changed;  39  in  which  it  was  slightly  granular, 
the  striations  still  being  visible;  46  in  which  the  muscle  was  granu- 
lar; 19  in  which  it  was  slightly  waxy;  1  in  which  there  was  granular 
degeneration,  and  1  in  which  it  was  very  waxy.  More  recently, 
Dewerve^  reports  that  in  48  cases  analyzed  by  him  the  heart  was 
found  softened,  pale,  and  of  a  "dead-leaf  color"  in  fifteen  instances, 
had  undergone  fatty  or  granular  degeneration  in  sixteen  instances, 
and  in  three  others  there  was  proliferative  endarteritis  of  the  small 
vessels  of  the  heart. 

It  is  worthy  of  note  that  these  changes  are  responsible  in  a 
large  proportion  of  cases  for  the  sudden  deaths  which  occur  in  the 
convalescent  period  of  the  disease,  even  more  commonly  than  in 
the  course  of  the  disease  itself.  So  frequent  is  this  condition  of 
sudden  cardiac  failure  an  accident  of  convalescence  rather  than 
of  the  febrile  attack,  that  Graves  stated  that  even  if  the  fever  has 
departed  and  everything  about  the  patient  is  favorable,  we  are  not 
justified  in  banishing  all  anxiety  or  in  relaxing  vigilance,  as  a 
sudden  effort  on  the  part  of  the  patient  may  cause  fatal  syncope. 
Instances  of  this  sort  have  been  recorded  among  the  older  writers 
by  Bailly,  Graves,^  Jaccoud,  and  Louis. 

Dewerve  also  found  in  analyzing  cases  of  sudden  cardiac  death 
that  it  occurred  most  frequently  in  persons  between  the  ages  of 

1  Dewerve.    De  la  Mort  Subite  dans  le  Fitvre  TjT>hoide,  Arch.  G^n.  de  Mdd.,  1887,  ii,  385. 
*  Graves     Clinical  Medicine. 


THE  CllidUr.ATION  IN  ('A)NV AJ.KSCESCE  105 

twenty-two  ;iii(l  twenty-five  ycjirs,  prohnhly  Ixtiiiisc  tlii  i.  llic  w^n- 
most  I'reqnently  ad'eeted  hy  enteric  l'ev(;r,  and  (liat  old  w^n-  un(J 
infancy  rarely  sn/lered  Ironi  it.  '^ri)e  aecidcul  itself  is  fur  more 
cominon  in  men  than  in  women,  I'or  (liis  wrih'r  foiind  il  in  ilic  pro- 
portion of  114  cases  in  men  to  20  in  women. 

It  is  interesting  to  note  that  this  condilion  is  iu)t  a  sef|uel  of 
severe  cases  alone,  for  Dewerve  asserts,  on  tlic  conirary,  that  it  is 
emphatically  a  sequel  of  a  moderate  form  of  the  fever  (forme  moy- 
eiinc).  Fnrther,  violent  effort  is  not  necessary  to  produce  it,  for 
it  has  occurred  after  so  slight  a  movement  as  extending  the  arm, 
by  emotion,  and  may  develop  without  any  such  cause,  the  patients 
being  found  dead  in  bed  in  the  posture  they  were  in  when  asleep. 
Liebermeister  records  the  case  of  a  woman  who  ate  a  hearty  dinner 
after  convalescence  from  a  mild  illness  of  typhoid  fe^•er.  She 
then  rose  to  go  to  the  closet,  fell  in  a  faint,  and  died  in  ten 
minutes;  and  another  case  of  a  man  who  was  unable  to  take  the 
upright  posture  for  many  weeks  without  suffering  from  nausea, 
vomiting,  collapse,  and  partial  syncope,  but  who  ultimately  recov- 
ered. The  autopsy  in  the  case  of  the  woman  revealed  no  lesions 
save  profound  cerebral  anjemia. 

(For  sudden  death  due  to  nervous  lesions,  see  chapter  on  devel- 
oped stage  of  the  disease,  nervous  symptoms.) 

There  are,  however,  other  causes  of  sudden  failure  of  the  heart 
than  myocardial  degeneration,  namely,  embolism  or  thrombosis  of 
the  coronary  artery  or  arteries,  heart-clot,  thrombosis  or  embolism 
of  the  cavse  or  pulmonary  veins,  and  pericarditis  with  effusion, 
which,  pressing  on  the  heart  when  a  change  in  position  is  attempted, 
causes  sudden  death.  In  the  cases  already  quoted  as  having  been 
analyzed  by  Dewerve  (48  cases),  there  were  eight  with  thrombosis 
of  the  coronary  arteries.  In  eight  other  cases  antemortem  clots 
were  found  in  the  right  ventricle.  lyiebermeister  reports  one  case 
at  Tubingen,  in  which  death  occurred  as  a  result  of  embolism  of 
that  branch  of  the  pulmonary  artery  that  goes  to  the  lower  lobe  of 
the  right  lung.  In  this  case  the  embolus  arose  from  thrombosis 
of  the  right  crural  vein,  and  was  accompanied  by  extensive  hemor- 
rhagic infarction.  Clots  in  the  coronary  arteries  may  arise  from 
within  the  heart  cavities  from  granulations  on  the  endocardium. 


198  coMPLiCATinxs  nuRixa  coxvalescence 

Beaiunaiioir/  Fritz,- Vallette/  Forgues/  Divwitt,'  and  others  have 
met  with  these  formations. 

According  to  Drcwitt,  however,  tliese  clots  are  formed  in  the 
heart  in  the  acute  period  of  the  disease,  and  then  are  dislodged 
when  the  circulation  increases  in  tone  during  convalescence. 

Viti"  has  found  the  bacillus  of  Eberth  in  the  granulations  of  endo- 
carditis, and,  furthermore,  has  produced  these  lesions  in  rahhits  by 
iiioculaling  tiiem  with  (lie  bacillus,  and  Vincent^  has  recorded  the 
case  of  a  previously  healthy  soldier,  who  died  from  enteric  fever,  and 
in  the  vegetations  of  his  mitral  valves  these  specific  bacilli  were 
found.  Girode^  has  made  a  similar  report.  Hayem,"  also,  has 
recorded  a  case  in  which  endocardial  difficulty  was  recognized  in 
life,  and  two  days  later  symptoms  of  plugging  of  the  arteries  in 
both  legs  ensued.  First,  pulsation  ceased  in  the  dorsales  pedes, 
•  then  in  the  popliteals,  and  finally  in  the  femorals,  and  gangrene 
developed.  An  embolus  was  found  mi  the  femoral  artery,  but  did 
not  extend  below  the  knee.  The  autopsy  showed  antemortem 
cardiac  clots,  endocarditis,  thrombosis  of  the  aorta,  and  multiple 
infarctions  in  the  kidney.  On  the  other  hand,  it  must  not  be  for- 
gotten that  endocarditis  complicating  typhoid  fever  is  rare.  Osier 
says  he  has  seen  but  three  cases  of  this  complication  in  his  series 
of  1500  cases,  but  states  that  the  physical  signs  were  such  as  to 
suggest  its  presence  in  three  other  patients.  In  a  series  of  793 
patients  suffering  from  typhoid  fever  at  von  Jaksch's  clinic  endo- 
carditis occurred  15  times.  Hawkins'"  has  also  reported  a  case. 
Only  eleven  cases  occurred  in  2000  cases  in  IMunich.  Pericarditis 
is  also  very  rare — 14  in  2000  cases  in  Munich  and  but  three  times 
in  Osier's  1500  cases,  while  from  von  Jaksch's  clinic  is  reported  but 
one  case  in  the  series  of  793  cases,  and  Hawkins  saw  but  one  case. 

'  Beaumanoir.     La  Piogros  Medicale,  1891,  ix,  364. 
2  Fritz.     Charitd  Annalen,  vi,  169. 

'  Vallette.  Contribution  il  I'Etude  de  la  Gangrene  des  Membreis  Pendant  la  Cours  de 
Fifevre  Typhoide,  These  de  Paris,  1890,  Ferrand. 

■•  Forgues.    Rec.  de  M^m.  de  M(3d.  Militaire,  1880,  3d  series,  xxxvi,  386 

=>  Drewitt.    Lancet,  1890,  ii,  1023. 

"  Viti.  Atta  della  Roy.  Acad,  del  Fitjiocritia  de  Siena,  4th  series,  vol.  ii,  fasc.  5  and  G,  1890. 

'  Vincent.    Merc.  Medicale,  February  17,  1892,  p   73. 

1  Girode.    Comptes  Rendu  Soc.  Biol.,  1889,  p.  622. 

»  Hayem.    Progrt's  Mddicale,  1875. 

'"  Hawkins.    Trans.  Clinical  Society,  London,  1907,  xl,  72. 


77//';  C/U,(Jl/LAT/(fN   IN   CONVALh'SC'h'NC'/'J  J(j7 

Grady  iitid  (lOiirand'  rcporl,  lliis  (•ondldoii  f(jmpli<;i(iiin-  ;i  mild 
attack  of  tyjjiioid  i'cvcv.  On  tlic  ciolilli  d;iy  of  I  lie  disease  a  diy 
pericarditis  (JcvolojK'd.  'I'licy  wen;  aMe  lo  find  but  thirty  iustanees 
in  the  literature  of  the  development  of  this  eornj)lication  during 
typhoid  fever.  Moore^  reports  two  eases,  on<'  in  a  hoy  and  one  in  a 
yonnjy  woman,  both  o('eurrin<!;  dtirinfi;  the  second  week  of  f(;ver 
and  both  recoverinji;. 

Liebermeister  tells  ns  that  endocarditis  is  rare  in  typhoid  fever, 
and  mentions  ])ut  one  case  of  the  severe  form,  accom];anied  by  a 
development  of  excessive  warty  growths  with  perforation  of  two 
of  the  semihmar  folds,  and  consecjuent  infarction  of  the  kidneys 
and  spleen,  double  pleural  pneumonia  and  death.  He  believes, 
however,  that  a  mild  form  of  endocarditis  without  ulceration  is 
more  commonly  met  with. 

In  other  cases  embolism  of  the  pulmonary  artery  results  from 
thrombosis  of  the  femoral  vein  and  causes  sudden  death.  Thus 
Nawercke^  records  a  case  of  this  character  in  which  the  patient 
dropped  dead  when  at  stool,  death  coming  on  in  ten  minutes,  and 
Bouley*  reports  a  case  of  ascending  thrombosis  of  the  femoral  veins 
into  the  cava  and  from  there  into  the  right  auricle. 

In  other  instances  an  endarteritis  may  involve  the  coronary 
vessels  and  cause  sudden  death,  if  we  can  rely  upon  the  views  of 
Landouzy  and  Siredey.^  These  investigators  tell  us  that  from  the 
clinical  point  of  view  the  manifestations  of  cardiovascular  disease 
in  typhoid  fever  may  present  two  different  aspects.  Sometimes 
the  rapid  spread  of  the  lesions  in  the  heart  and  vessels  is  accom- 
panied by  a  rapid  pulse,  with  great  feebleness  of  the  heart;,  and, 
perhaps,  by  its  sudden  arrest.  In  other  instances,  on  the  contrary, 
these  changes  are  developed  so  slowly  and  insidiously  that  death 
occurs  more  or  less  remotely  and  with  variable  degrees  of  cardio- 
pathic  change.     The  symptoms  usually  met  with  in  the  first  variety 

'  Grady  and  Gourand.      Gaz.  des  Hopitaux  de  Paris,  1903. 

2  Moore.    St.  Bartholomew's  Hospital  Reports,  1903. 

3  Nawercke.     Correspondenzblatt  fiir  Schweizer  Aerzte,  1879,  p.  485. 
*  Bouley.    Progrfes  Medicale,  18S0,  viii,  998. 

^  Landouzy  and  Siredey.  Contribution  a  I'Histoire  de  I'Arterite  Typhoidique,  Rev.  de 
M^decine,  1885.  Those  interested  should  also  read  a  paper  by  Landouzy  and  Siredey, 
Etude  des  Angiocardiaques  Typhoidiques  Leurs  Consequences  Immediates,  Prochaine  et 
Eloign^es,  Revue  de  M^d.,  1887,  p.  804. 


198  COMPLICATIOXS  DURIXC  COXVALESCEXCE 

may  be  classed  as  those  of  collapse,  with  great  tVihleness  in  the 
cardiac  muscle.  The  pulse  becomes  extremely  rapid,  small, 
irreijular;  the  face  is  livid,  the  eves  sunken,  the  voice  feeble,  and 
the  extremities  cold.  The  temperature  may  be  subnoi-mal.  The 
urine  is  scanty  or  suppressed.  The  respirations  are  embarrassed, 
and  the  lungs  are  affected  by  hypostatic  congestion.  Finally, 
coma  and  death  come  on.  This  form  of  collapse  may  come  on  as 
early  as  the  second  or  third  week.  The  feeble  apex  beat  and 
rapid  pulse  indicate  a  diffuse  alteration  in  the  heart  muscle,  which 
is  usually  a  fatty  degeneration  of  its  fiber  "granulo-graisseuse." 
In  cases  of  sudden  death,  on  the  other  hand,  the  lesions  are  chiefly 
connected  with  the  walls  of  the  cardiac  vessels,  the  symptoms  being 
in  abeyance  for  the  most  part  until  the  fatal  moment,  but  dependent 
upon  gradually  increasing  degenerative  processes. 

In  other  cases  where  the  changes  are  less  marked,  the  patient 
does  not  suffer  from  severe  and  alarming  symptoms,  but  instead  of 
these  the  patient  is  affected  by  a  disordered  circulation  and  lack  of 
tone  in  the  heart  and  vessels.  The  chief  signs  of  these  conditions 
are  intermittence  of  the  pulse  and  a  harsh  diastolic  murmur  at  the 
cardiac  base. 

The  cardiac  lesions  in  mild  cases  may  be  entively  recovered  from 
so  far  as  symptoms  are  concerned,  but  the  actual  lesions  themselves 
often  remain,  and  Landouzy  and  Siredey  record  a  case  in  which  a 
second  attack  of  typhoid  fever  came  on  two  years  after  the  first, 
and  at  the  autopsy  old  and  new  lesions  were  found  in  the  myocar- 
dium. 

As  a  matter  of  fact,  the  cardiac  changes  of  typhoid  fever  are 
closely  allied  to  those  that  are  found  in  cases  affected  by  other 
infectious  diseases  of  a  severe  type. 

Sudden  death  in  typhoid  fever  may  occur  as  early  as  the  tenth 
day.  INIery  reported  such  a  case  to  the  Soci^te  Anatomique  in 
October,  1887.  He  states  that  the  myocardium  did  not  show  any 
histological  changes  and  that  the  patient  had  been  treated  by  the 
Brand  bath.  In  discussing  this  case,  Cornil  spoke  of  the  diffi- 
culty of  discovering  any  satisfactory  cause  for  these  accidents,  and 
referred  to  the  fact  that  some  persons  believed  them  to  be  due  to 
changes  in  the  nervous  ganglion  of  the  heart — an  hypothesis  which 
is  difficult  of  verification. 


77//';  (J/MJULAT/ON  IN  C'ONVALKSC/'JiVC/':  \<.)<) 

Pericarditis,  us  already  statefl,  is  rarely  due  to  typFioid  infec- 
tion, although  it  may  eoniplirafe  its  course,  being  pnxJured  |>y 
another  cause.  Thus,  Ilutcln'nsfjii  recf>rr|.s  it  c;ise  in  whieh  ;i  j>;i(icijt 
convalescing  from  enteric  fever  suffered  from  erysi}>elas,  then 
from  pleurisy,  and  finally  from  pericarditis.  Snrely  this  case  was 
due  rather  to  the  streptococcus  than  (o  llie  hacilhis  of  Eherth. 
Liebermeister  only  saw  foni-  e;ises  of  perienrditis,  ;iiid  ;dl  recovered. 

Very  rarely  sudden  death  ensues  without  (;ur  being  able  to  find 
any  of  the  causes  given.  D{\]hrine^  lias  recorded  two  such  cases, 
in  which  no  sign  of  cardiac  degeneration  could  be  found.  In  such 
instances  an  embolism  of  an  artery  supplying  an  important  vital 
spot  in  the  medulla  may  be  the  cause. 

Dieulafoy-  asserts  that  in  such  cases  there  may  be  another  cause 
of  death,  namely,  reflex  irritation  along  the  vagus  from  the  abdom- 
inal cavity,  and  which,  being  transmitted  along  the  efferent 
branches  of  this  nerve,  inhibits  the  heart's  action  and  causes  fatal 
syncope.  In  other  instances  he  thinks  that  the  respiratory  centre 
is  rapidly  affected,  and  that  death  results.  Such  reasoning,  in 
view  of  our  knowledge  of  the  functions  of  the  parts  of  the  ner- 
vous system  just  named,  seems  very  hypothetical. 

Death  due  to  the  causes  enumerated  may  come  on  more  gradu- 
ally than  has  been  intimated  so  far.  Thus  dyspnoea,  irregularity 
of  the  pulse,  a  bruit  de  souffle,  and,  rarely,  partial  syncope,  may 
begin  the  end. 

Passing  from  these  changes  to  those  met  with  in  the  general 
bloodvessels,  w^e  find  that  marked  inflammatory  processes  often 
affect  these  parts  in  the  course  of  typhoid  fever.  One  of  the  most 
important  studies  made  upon  this  subject  is  that  of  Barie,^  who 
asserts,  as  a  result  of  his  work,  that  both  the  large  and  small  ves- 
sels may  be  affected  by  inflammation,  although  the  vessels  of  the 
lower  extremities  are  the  ones  most  often  and  most  severely  affected. 
Thus  in  t^s'enty-two  out  of  twenty-four  cases  this  was  true.  It 
takes  place  generally  when  the  patient  first  leaves  his  bed  and 
begins  to  move  about.     It  is  just  as  apt  to  follow  mild  as  severe 

'  Dt^jferine.    Comptes  Rendu  Soci^t^  Biologie,  1885,  p.  769. 
-  Dieulafoy.    De  la  Mort  Subite  dans  la  Fie\Te  Tj-phoide,  Paris,  1869. 
'  Barie.     Contribution  a  I'Histoire  de  I'Arterite  Aigue  Consecutif  a  la  Fievre  Tj"phoide, 
Revue  de  Medecine,  1883,  p.  1,  and  1884. 


200  COMPLICATIOXS  DURIXG  COXVALESCENCE 

attacks,  and  it  occurs  in  two  forms,  namely,  as  an  acute  obliterating 
arteritis  and  as  an  acute  parietal  arteritis.  He  describes  the  change 
as  follows: 

"The  first  variety  is  constituted  anatomically  by  an  embryonal 
infiltration  of  the  three  coats,  and  disappearance  of  the  smooth  con- 
tlition  of  the  intima,  which  becomes  uneven  and  granular.  This 
leads,  as  a  consequence,  to  the  pioduction  of  a  secondary  throm- 
bosis, which  in  course  of  time  becomes  a  dense  gray  mass  adherent 
to  the  parietes  of  the  artery.  Very  often  the  inflammation  of  the 
artery  is  accompanied  by  a  certain  amount  of  periarteritis.  If  the 
lumen  of  the  afi'ected  artery  is  completely  obliterated  and  the  col- 
lateral circulation  is  not  c|uickly  established,  mortification  ensues, 
and  the  limb  assumes  the  appearance  of  dry  gangrene.  In  excep- 
tional cases,  in  consequence  of  the  simultaneous  occurrence  of 
venous  thrombosis  or  of  phlebitis,  moist  gangrene  may  follow  the 
mummifying  variety,  or  substitute  itself  for  it. 

"The  principal  symptoms  of  obliterating  arteritis  are  as  fol- 
lows: Acute  pain  occurring  more  or  less  suddenly  and  seated  in 
the  course  of  the  affected  artery,  sometimes  localized  in  a  restricted 
region,  as,  for  instance,  the  thigh,  calf,  or  Scarpa's  triangle,  some- 
times occupying  the  whole  length  of  the  limb,  and  increased  by 
pressure  upon  assuming  the  erect  position  and  by  the  movements 
of  walking;  diminution  of  the  fulness  and,  finally,  suppression  of 
the  pulsations  of  the  artery;  swelling  of  the  limb  without  a-dema 
or  redness;  bluish  mottling  of  the  skin;  sometimes,  although 
rarely,  purpura;  diminution  of  the  temperature  of  the  limb  with 
or  without  disturbance  of  sensibility,  such  as  formication  and  par- 
tial ansesthesia,  and,  finally,  the  occurrence  in  the  course  of  the 
artery  of  a  hard  and  tender  cord. 

"The  parietal  arteritis  is  only  a  variety  of  the  preceding,  and  has, 
consecjuently,  the  same  symptoms  but  in  a  less  degree  of  develop- 
ment, except,  of  course,  that  tlie  liard,  painful  cord  is  absent.  It  is 
said,  however,  that  the  diminution  of  the  pulsations  of  the  artery 
is  occasionally  preceded  by  an  exaggeration  of  their  amplitude, 
and  that  in  a  few  cases  the  temperature  of  the  afi'ected  limb^has 
been  observed  to  be  higher  than  that  of  the  other. 

"It  must  be  borne  in  mind  that  some  of  the  symptoms  of  the 


Till':  cmcuLA'/'ioN  IN  (;()NVArj<:s(:HS'(:i':  2i)\ 

ol)liter;ifMi^  Vfiricty  may  Jii'i.sc  from  aJi  embolus,  hut  tijo  prosr-rir-r; 
of  a  valvular  iiujrniur  and  of  other  .signs  of  disease  of  the  heart, 
and  the  suddenness  of  (he  seizure,  will  enaf)le  us  to  recognize 
without  difficulty  the  eases  dependent  upon  this  cause. 

"The  therapeutic  indications  in  the  milder  forms  are  best  ful- 
filled by  rest  in  bed,  the  aj)plication  of  eniollients  or  soothing 
ointments  to  the  limb,  and  wrapping  it  in  cotton.  In  easfs  in 
which  gangrene  has  occm-red  the  [)atient  should  be  suj^jjorterl  by 
tonics  and  a  liberal  diet,  and  appropriate  antiseptic  dressing  should 
be  applied  to  the  part." 

Other  reports  on  this  subject  have  been  made  by  Ferrand,* 
Deschamps,^  Mettler,^  Quervain,'*  and  Haushalter.'' 

In  addition  to  these  interesting  researches,  there  are  others  of 
even  greater  interest,  as,  for  example,  those  of  Rattone,"  who  in 
four  cases  found  the  bacillus  of  Eberth  in  the  arterial  walls  and 
obtained  pure  cultures  from  this  source.  The  result  of  this  infec- 
tion and  endarteritis  is  to  aid  in  the  formation  of  thrombi,  and 
these  in  turn,  by  plugging  of  the  vessel,  cause  rapid  dry  gangrene 
of  the  tributary  part.     (See  lesions  in  the  skin.) 

The  bacilli  are  supposed  to  reach  the  arterial  wall  by  the  blood 
stream  rarely,  or  by  the  blood  stream  in  the  vasa  vasorum. 

The  veins  are  very  much  more  apt  to  be  affected  by  thrombus 
than  the  arteries,  as  everyone  with  a  large  experience  with  t}^hoid 
fever  well  knows.  Haushalter  and  Vaques  have  found  the  bacilli 
in  the  walls  of  these  vessels,  and  Rattone  and  Haushalter  have 
found  them  in  the  thrombi  themselves,  and  also  that  the  endothe- 
lium under  the  clot  was  destroyed. 

As  a  result  of  this  thrombosis  with  phlebitis  we  may  have  devel- 
oped phlegmasia  alha  dolens,  but  very  rarely  gangrene,  because 
the  collateral  circulation  is  more  free  in  the  veins. 

The  clots  in  the  veins  may  be  single  or  multiple,  and  may  be  of 
very  extraordinary  size.     In  De  Santi's'  case  a  clot  extended  from 

'  Ferrand.    These  de  Paris,  1890.  -  Deschamps.     Ibid.,  1886. 

3  Mettler.    Philadelphia  Medical  Times,  February  19,  1887,  p   339,  and  New  York  Medical 
Journal,  March,  1S95,  p.  289. 

■■  Quervain.    Centralblatt  fiir  innere  Med.,  August  17,  1895,  p   793. 

6  Haushalter.    Mercredi  M(fdicale,  September  20,  1893,  p.  453. 
^  Rattone     Delia  Arterit^  Tifosa  in  Dehu. 

7  De  Santi.    Ree.  M(im.  de  Med.  Milit.,  1879,  series  3,  xxxv,  502. 


202  COMPLICATIONS  DURIXG  COXVALESCEXCE 

the  vena  cava  in  the  iliac  vein  down  into  the  femoral  vein,  and 
one  extraordinarv  case  is  recorded  by  Beaumanoir/  in  which  clots 
were  in  the  arteries  of  both  legs,  in  the  right  ventricle,  in  the  pul- 
monary artery,  in  tlio  femoral  veins,  and  in  the  aorta.  Cases  of 
clots  reaching  from  the  femoral  vein  to  the  vena  cava  are  recorded 
by  Dumontpalier,-  Sorel,^  Bouley,'  and  Mackintosh.'"  A  case  of 
thrombosis  of  the  iliac  veins  and  the  lower  part  of  the  ascending 
vena  cava  has  been  reported  by  Pansini."  Oedema,  lividity,  pain, 
and  loss  of  power  in  the  legs  were  present.  Pansini  refers  to  a 
statistical  article  of  Vimont,  who  up  to  1S90  collected  112  cases 
from  the  literature  of  this  character. 

A  curious  case  of  varicosity  of  the  subcutaneous  veins  of  the 
trunk  and  extremities  is  reported  by  Mackintosh.^  The  veins 
involved  were  the  jugular  and  internal  mammary  and  external 
pudic,  the  superficial  epigastric,  internal  saphenous,  and  superfi- 
cial circumflex  on  both  sides.  It  is  supposed  by  the  reporter  that 
a  thrombus  formed  at  the  junction  of  the  iliac  veins  and  inferior 
vena  cava,  which,  becoming  engorged,  necessitated  a  collateral  cir- 
culation.    Curiously  enough,  the  patient  survived. 

Plugging  of  the  veins  to  a  great  degree  usually  results  in  moist 
gangrene,  as  has  already  been  stated. 

In  regard  to  the  vessels  most  commonly  affected  by  plugging, 
we  gain  very  interesting  information  from  Keen's  classical  essay. 
Out  of  90  cases  of  gangrene,  and  Keen  believes  all  these  cases 
w^ere  due  to  plugging  of  vessels,  46  had  arterial  plugging,  of 
which  8  were  bilateral,  19  on  the  right  side,  and  19  on  the  left 
side.  In  the  veins  in  52  cases  there  was  bilateral  involvement  on 
both  sides  in  4  cases;  on  the  right  side  in  10  cases,  and  on  the  left 
side  in  38  cases.  Again,  in  those  cases  which  did  not  proceed  to 
gangrene,  Keen  found  plugging  in  the  arteries  in  15  cases,  of  which 
4  were  bilateral,  6  on  the  right  side,  and  5  on  the  left,  and  in  the 
veins,  out  of  47  cases,  3  were  bilateral,  13  on  the  right  side,  and  31 
on  the  left. 

1  Beaumanoir.    Progrfes  M^d.,  1891,  ix,  364. 

2  Dumontpalier.    Comptes  Rendu  Soc.  Biol.,  1879,  6th  series,  vol.  iv,  parts  283. 

3  Sorel.    L'Union  Mddicale,  1882,  p.  521.  *  Bouley.    Progrfes  Mdd.,  1890,  viii,  998. 
^  Mackintosh.    Glasgow  Med.  Journal,  1892,  xxviii,  54. 

8  Pansini.    Centralblatt  fiir  innere  Med.,  June  6,  1896. 
^  Mackintosh.    Glasgow  Medical  Journal,  July,  1893. 


77//';  ailiCULATION  IN   CONVAL/'JSC/'JNC/'J  203 

These  sljitistics  ,siij)|)(»cl,  (Ix-  ciullcr  ones  [)re.serite(l  to  us  ])y 
Liebermeister,  who  mcl,  with  -U  cases  of  (lirorribosis  in  (he  veins 
of  the  lower  extreniilics  ainon^  ]71.'>  typhoid  fever  f^atients,  the 
majority  of  whom  were  men.  In  his  cases  also  thiomhosis  usually 
(lid  not  aj)|)ear  until  the  stage  of  eonvaleseenee,  anrl  rarely  as  early 
as  the  third  or  fourth  week.  (Jut  of  24  cases,  16  of  which  were  in 
men  and  8  in  women,  the  vessels  became  plugged  eighteen  times 
in  the  criu-al  vein,  five  times  in  the  saphenous  vein,  and  once  in 
the  popliteal  vein.  'J'hrombosis  of  the  crural  vein  took  place  in 
both  sides  simultaneously  twic;e,  four  times  on  the  right  side, 
and  twelve  times  on  the  left.  The  saphenous  vein  was  affected  on 
the  right  side  once,  and  on  the  left  side  four  times,  and  the  throm- 
bosis in  the  popliteal  vein  was  also  left-sided;  in  other  words,  this 
accident  occurred  five  times  on  the  right  side  and  seventeen  times 
on  the  left.  The  frequent  occurrence  of  thrombosis  in  the  left 
crural  vein  rather  than  the  right  is  believed  by  Liebermeister  and 
by  Keen  to  be  due  to  the  slight  pressure  exercised  upon  the  left 
common  iliac  vein  by  the  right  common  iliac  artery,  thereby  com- 
pressing the  vein.  H.  C.  Jonas^  reports  a  case  of  phlebitis  of  both 
femorals  associated  with  periostitis  of  the  right  tibia. 

Sometimes  phlebitis  of  the  calf  of  the  leg  develops  in  place  of 
thrombosis  of  the  femoral  vein.  Thus  Arnaudet"  records  three 
cases,  one  in  a  woman  aged  seventy-five  years,  another  in  a  woman 
aged  fifty  years,  and  the  last  in  a  man  aged  thirty-eight  years. 

A  few  years  ago  one  of  us  (Hare)  had  under  his  care  a  case  of 
this  kind  occurring  in  a  girl  of  twenty  years,  on  the  left  side.  In 
Arnaudet's  cases,  one  was  on  the  left  side,  the  other  two  on  the  right. 

The  rarity  with  which  plugging  of  a  vessel  in  the  upper  extremi- 
ties takes  place  is  remarkable.  Thus,  in  128  cases  of  phlebitis 
collected  by  Keen,  only  4  involved  the  upper  extremities  alone; 
2  involved  the  arm  and  leg,  and  124  were  limited  to  the  legs. 

Thrombosis  of  either  an  iliac  or  femoral  vein  is  always  a  serious 
complication.  The  immediate  dangers — ^gangrene,  extension  of 
th  ^  thrombus,  and  pulmonary  embolism — are  not  great,  but  the 
remote  effects  are  often  grave.     In  cases  of  thrombosis  of  the 

1  Jonas.    Lancet,  October  4,  1903. 

2  Arnaudet.    La  Normandie  M^d.,  Xovember  1,  1S91. 


204  COMPLICATIONS  DURIXG  COXVALESCEXCE 

tVmoral  or  iliac  vein  tlu>  aHVcted  extremity  is  always  considerably 
and  permanently  enlarged,  and  there  is  nsnally  more  or  less  per- 
sistent disability. 

Thayer'  has  made  an  exlianstive  stntly  of  the  cardiac  and  vas- 
cular complications  and  sequels  of  typhoid  fever,  and  his  conclu- 
sions are  so  important  and  agree  so  perfectly  with  onr  own  observa- 
tions that  we  quote  freely  from  his  article. 

That  typhoid  fever  is  a  disease  in  which  weakness  of  the  heart 
nuiscle  is  a  (|uite  constant  contlition  is  oenerally  recognized. 
^^'llether  this  weakening  is  brought  about  by  the  direct  action  of 
the  toxin  of  the  typhoid  bacillus  on  the  heart  muscle  or  by  impair- 
ment of  its  nutrition,  the  result  is,  in  a  considerable  number  of 
cases,  a  temporary  insufficiency  of  the  mitral  valve,  as  indicated  by 
the  appearance  of  a  systolic  mm-mur  at  the  apex,  which  not  infre- 
quently is  transmitted  toward  the  axilla.  These  murmurs  usually 
appear  during  the  height  of  the  fever  and  disappear  with  con- 
valescence. There  are,  however,  a  certain  number  that  persist. 
In  12  of  Thayer's  188  cases  of  typhoid  fever,  which  were  kept  under 
observation  from  three  months  to  fourteen  years  after  the  attack, 
he  found  signs  which  led  him  to  ])elieve  that  an  organic  cardiac 
lesion  was  present.  In  the  majority  of  these  cases  an  apical  sys- 
tolic min-miu"  had  been  discovered  dui'ing  the  attack  of  typhoid 
fever.  In  over  one-fifth  of  the  patients  in  whom  during  the  attack 
of  typhoid  fever  a  cardiac  murmur  was  heard,  subsequent  examina- 
tion revealed  evidence  of  organic  heart  disease.  It  was  also  noted 
that  the  radial  arteries  of  those  cases  which  had  had  an  attack  of 
typhoid  fever  were  much  more  readily  jjalpable  than  were  those  of 
patients  who  had  not  been  victims  of  this  disease.  That  arterial 
changes  take  place  is  indicated  by  the  fact  that  Thayer  found  the 
average  systolic  blood  pressure  to  be  higher  among  those  persons 
who  had  previously  been  ill  of  typhoid  fever  than  in  those  patients 
who  had  not  had  this  disease.  These  findings  by  Thayer  of 
higher  systolic  blood  pressure  than  normal  in  patients  formerly 
victims  of  typhoid  fever  would  seem  to  indicate  that  the  heart 
muscle  could  not  have  been  permanently  damaged  or  the  function 

'  Thayer.     American  Journal  of  the  Medical  Sciences,  1904,  p.  137;  also  Johns  Hopkins- 
Bulletin,  1904,  p.  1,5. 


(IHNITO-dlUNAKY  205 

of  the  valves  impjili-cd,  l)ii(,  on  tlic  oIIkt  IkukI,  il  may  also  Ix-  (lie 
case  tliat  tlic  discMsc  cjiiiscs  iu'lcriiil  cliaiiifcs  vvliirli,  ))y  fl('rri;i.ri<iiti^ 
incrcMsed  hihor,  pi-oduct!  ('OinjK'iisalory  hyfx-rfropliy,  wliirli  in  time 
jijives  rise  to  tlie  hif^h  systolic  pressiin;  noted  liv  Tlijiycr. 

Arteritis  and  arterial  thrombosis  are  eoiisidered  by  'J'liayer'  to 
be  more  frecjiient  complications  of  typhoid  fever  fli;in  are  usually 
thou^rjit.  This  complication  is  especially  connnon  in  the  cerebral 
vessels,  although  it  may  occur  in  the  extremities.  I'he  onset  of  this 
condition  may  be  as  early  as  the  second  week  of  the  disease,  but  it 
more  commonly  occurs  later  in  the  attack.  As  in  phlebitis,  this 
complication  is  often  ushered  in  by  fever  and  leukocytosis.  When 
arterial  thrombosis  occurs  in  the  extremities,  it  is  often  followed  by 
gangrene,  and  when-  in  the  cerebral  vessels,  by  hemiplegia. 

Genito-urinary. — Orchitis  complicating  typhoid  fever  during 
the  progress  of  the  febrile  stage  is  rare,  but  a  case  was  recorded 
by  Marcus,^  in  1812,  of  suppuration  of  the  scrotum  in  "stupid 
nervous  fever."  Vulpian^  also  states  that  this  complication  may 
follow  grave  fevers.  It  is  emphatically  a  symptom  of  the  period 
of  convalescence.  Westcott  collected  for  Keen  thirty-two  cases, 
while  Eshner,*  in  1898,  collected  forty-two  cases,  and  reported  one 
in  his  own  care.  The  contribution  of  OUivier^  to  the  study  of 
typhoid  orchitis  is,  however,  very  exhaustive,  and  to  him  belongs  the 
credit  of  summarizing  most  of  the  literature  up  to  1883.  A  case 
of  this  kind  was  under  the  care  of  one  of  us  (Hare);  its  history 
is  as  follows: 

The  patient  was  a  physician,  aged  twenty-two  years,  who  was 
admitted  to  the  wards  in  the  Jefferson  College  Hospital  on  January 
29,  1898,  with  a  history  of  having  been  ill  for  ten  days  with  frontal 
headache  lasting  four  days,  with  pains  in  the  lumbar  region,  and 
with  general  debility.  There  was  diarrhoea,  with  copious  watery 
evacuations  from  the  bowel,  and  rose  spots  were  present  upon  the 
cheeks  and  the  abdomen.  Nose-bleed  occurred  after  the  patient 
came   under  observation.     Examination   of  the   blood  yielded   a 

1  Thayer.    Johns  Hopkins  Medical  Bulletin,  October,  1904. 
^  Marcus.    Archiv  fiir  med.  Erfahrungen,  Berlin,  1S12.  i.  546. 
'  Vulpian.     Dictibnnaire  de  Med..  1S44.  2d  ed.,  xxix. 
*  Eshner.    Philadelphia  Medical  Journal,  Ma 3'  21.  1S98. 
6  Ollivier.    Revue  de  M(?decine,  1883,  pp.  829,  960. 


206  co^rPIJCATIOxs  nrnixc;  coxvalescexce 

positive  reaction  to  the  Gruber-AVidal  test.  The  urine  was  albu- 
minous on  each  of  three  occasions,  but  tube  casts  were  not  found. 
The  disease  pursued  an  ordinary  and  uncomphcated  course, 
defervescence  taking  place  on  February  22,  and  the  patient 
was  dismissed  well  on  March  13.  On  March  2S  he  was  seized^ 
without  obvious  cause,  with  pain  and  swellino-  in  the  left  testicle. 
The  pain  was  agonizing,  and  the  swelling  gradually  increased 
until  the  testicle  became  many  times  its  normal  size.  Dr.  Hor- 
witz  noted  the  pain  as  being  intense  in  a  degree  far  l)eyond  that 
ordinarily  encountered  in  cases  of  orchitis  of  gonorrhceal  oriy;in. 
The  temperature  was  as  high  as  101°  between  March  31  and  April 
2,  and  it  reached  100.3°  on  April  10.  Otherwise  it  was  prac- 
tically normal.  There  was  also  no  urethritis  or  urethral  discharge. 
A  slight  effusion  into  the  vaginal  tunic  took  place,  but  there  was 
no  noteworthy  involvement  of  the  epididymis.  With  the  appli- 
cation locally  of  an  ice-bag,  and  of  mercurial  and  belladonna 
ointments,  and  the  internal  administration  of  opiates,  pain  was 
relieved  and  swelling  subsided;  but  it  became  evident  than  an 
abscess  was  forming  in  the  left  half  of  the  scrotum.  Accordingly, 
an  incision  was  made  by  Dr.  Horwitz  on  April  23,  and  a  consid- 
erable quantity  of  pus,  together  with  a  portion  of  the  testicle, 
was  evacuated.  The  operation  was  successful,  and  the  patient 
recovered. 

Ollivier^  believes  that  orchitis  is  more  common  than  is  generally 
thought.  He  reports  three  cases  of  his  own.  Liebermeister"  met 
with  it  3  times  in  250  cases,  and  SoreP  found  it  in  3  cases  out 
of  871  typhoid  fever  cases  seen  in  ten  years.  In  Osier's  series  of 
1500  cases  this  condition  occurred  but  4  times,  being  commonly 
associated  with  a  catarrhal  urethritis  and  coming  on  usually  during 
the  last  week  in  bed  or  during  convalescence.  Eshner,  however, 
quotes  Betke,^  who  did  not  meet  with  it  in  the  records  of  1420  cases, 
and  Dopfer,^  among  927  fatal  cases,  did  not  meet  it  once.    Holscher," 

1  Ollivier.    Revue  de  M^decine,  1883,  iii,  829,  861. 

*  Liebermeister.    Ziemssen's  Handbuch  du  speciellen  Path,  und  Therap.,  1874,  ii,  Band  ii, 
189. 

'  Sorel.    Bulletin  et  Mdm.  de  la  Soc.  M^d.  des  Hop  ,  1889,  Ivi,  236. 

*  Betke.    Deutsche  Klinik,  1870,  42  and  48. 

*  Dopfer.    Miinchener  med.  Wochenschr.,  1888,  p.  620. 
«H6lscher.    Ibid.,  January  20.  1891,  p.  43. 


(;i':NiT()-uiiiNAJiV  207 

in  the  celebratod  2000  fascs  in  Miiiiu;!),  r(;f:ord.s  a  caseous  orfliiti.s 
in  but  one  instjuice. 

Since  l^lslnicr's  exliiiiislivc  conlrihiilion  (o  (liis  .siiLjcff  in  1-S08, 
Kinnicutt  has  collected  addilioiuil  cases  and  icpoilcd  luo  (•■■.aiiijdcs 
in  his  own  j)ractice.  Hlinncnreld  a|,^ain  icvicvvcd  the  literature  in 
his  Paris  Thesis  for  1005,  and  added  a  case  under  his  own  ob- 
servation which  when  added  to  the  4  cases  recorded  by  fine  of  us 
(Beardsley^)  brings  the  cases  on  record  to  102. 

We  find  in  this  series  of  102  cases  that  71  instances  occurred 
during  convalescence  from  typhoid  fever  and  during  the  fever  in  ]  7, 
while  no  note  is  made  concerning  the  time  of  occurrence  in  the 
remaining  14  cases.  Tliere  is  no  apparent  relationship  between 
the  severity  of  the  original  disease  and  the  occurrence  of  the  com- 
plication, which  occurred,  with  equal  severity,  in  mild  and  severe 
attacks. 

The  onset  of  the  complication  is,  as  a  rule,  abrupt,  coming  on 
while  the  patient  is  still  in  bed  or  shortly  after  leaving  his  bed, 
and  is  marked,  in  the  majority  of  cases,  by  an  acute  pain  in  the 
region  of  the  testicle  or  in  the  groin.  If  the  pain  begins  in  the 
groin  it  is  radiating  in  character  and  involves  the  testicle.  The 
onset  is  frequently  marked  by  a  sense  of  chilliness  and  occasionally 
by  a  severe  chill.  The  pain  is  frequently  so  severe  as  to  cause 
vomiting.  Following  the  initial  chill  and  pain  there  is  usually 
a  rise  in  temperature,  acceleration  of  the  pulse,  and  a  feeling  of 
general  wretchedness.  In  many  cases  the  patient  complains  of  a 
sense  of  weight  in  the  testicle,  and  the  scrotum  is  often  red,  swollen, 
and  oedematous,  while  not  infrequently  an  acute  hydrocele  develops. 
Pain  on  urination  is  a  frequent  complaint,  and  catheterization  is 
sometimes  necessary.  The  complication  occurs  most  frequently 
in  youths  and  young  adults,  but  one  instance  is  recorded  in  a  boy, 
aged  four  years,  and  one  in  a  man,  aged  seventy-eight  years. 

The  testicle  is  usually  primarily  attacked,  and  in  some  instances 
the  inflammation  does  not  extend  to  adjacent  tissues,  while  in  other 
cases  the  epididymis  suffers  alone  or  is  first  attacked.  In  the 
majority  of  instances,  however,  both  organs  suffer. 

Thus,  in  the  102  recorded  cases,  orchitis  occurred  alone  in  31 

1  Beardsley.    Journal  of  the  American  Jledical  Association,  March  2S,  190S, 


208  COMPLICATIOXS  DURIXG  COXVALESCENCE 

and  epididymitis  alone  in  10,  while  in  43  patients  both  the  testicle 
and  epididymis  were  involved.  In  IS  of  the  cases  the  conditions 
were  not  diti'erentiated.  The  cord  was  involved  in  the  inflamma- 
tion in  a  luiniher  of  cases.  The  ri^-ht  side  was  affected  o7  times, 
the  left  27,  in  3  the  condition  was  bilateral,  while  in  35  cases  no 
note  was  recorded  as  to  the  side  affected. 

Suppuration  occurred  in  22  of  the  102  cases,  and  in  many  of 
these  there  was  a  loss  of  testicular  substance  and  subsequent 
atrophy.  It  was  noted  that  there  was  an  effusion  into  the  tunica 
vaginalis  testis  in  13  cases,  and  in  6  a  urethral  discharge  was  seen, 
while  in  several  instances  an  examination  of  the  m-ine  revealed 
the  presence  of  mucus  and  pus. 

The  comphcation  lasts,  as  a  rule,  from  a  few  days  to  a  week,  but 
when  suppuration  takes  place,  convalescence  is  delayed. 

For  many  years,  in  fact  imtil  recently,  when  orchitis  or  epididy- 
mitis occurred  during  or  following  typhoid  fever,  the  true  cause 
was  not  known,  and  various  reasons  were  ascribed  for  the  appear- 
ance of  the  condition.  The  most  popular  theory  was  that  the 
comphcation  was  the  result  of  a  preexisting  gonorrhoeal  infection, 
and  this  view  was  strengthened  by  the  knowledge  that  not  in- 
frequently there  was,  at  the  time  the  comphcation  was  noted,  a 
urethral  discharge  with  complaint  of  pain  on  urination.  Another 
theory  was  that  the  lesion  was  traumatic  in  origin,  and  in  many 
instances  slight  traumatisms,  such  as  injury  by  contact  with  a 
urinal  or  bed  pan,  or  injury  of  the  genital  tract  during  cathe- 
terization, was  held  accountable  for  the  production  of  the  condi- 
tion. Other  theories  advanced  were  that  the  accident  was  due  to 
a  "rheumatic"  condition  of  the  blood  or  by  an  infection  with 
pus-producing  germs,  while  Buccpioy  asserted  that  the  condition 
was  brought  about  by  masturbation  during  the  convalescence  from 
typhoid  fever.  A  better  understanding  of  these  complications 
has  been  brought  about  since  Widal  and  Chantemesse  found 
the  Bacillus  typhosus  in  the  testicles  of  patients  who  died  during 
typhoid  fever,  and  since  Schottmiiller,  in  1002,  pointed  out,  and 
proved  conclusively,  that  typhoid  fever  is  primarily  a  septicaemia, 
and  that  typhoid  bacilli  are  in  the  circulating  blood  in  even  the 
mildest  cases.    It  has  become  evident  that  the  orchitis  and  epididy- 


ALJMKNTAUY    TItACT  IN   CONVAU'lSCI'lNCI-l  209 

niiti.s  is  due  (o  it  locjiliziilioii  of  (he  l);ifilli  m  llic  lissiics  oi"  (lif.se 
or<i;jui.s  wlictlicr  (lie  lociiliziilion  is  u  result  of  Kiifjlli  Imviji^  ix-cri 
carried  by  tlic  blood  sln-iiin  or  in  cases  of  biieilliiii;i  by  way  oC  the 
vas  deferens.  It  is  probable  llial  (he  blood  slicam  is  llic  fiiodc  of 
infection  in  the  majority  of  cases,  but  now  tliat  we  know  Ikjw  oft(;n 
l)acilluria  exists  in  typhoid  fever,  we  must  consider  the  possi- 
bility of  infection  by  way  of  the  vas  deferens;  thus  in  one  case 
reported  by  Kinnicutt,  the  progress  of  the  eoiHliiion  eould  bf 
watched  from  tlie  time  it  involved  the  cord,  then  tli<"  e[>ididyrnis, 
and  at  last  the  testicle.  Thrombosis  of  the  spermatic  veins  has 
been  held  responsible  for  this  complication  in  several  instances, 
and  in  several  of  these  cases  the  condition  has  been  complicated  by 
phlebitis  of  the  saphenous  veins.  The  theory  that  phlebitis  of  the 
spermatic  and  testicular  veins  is  accountable  for  cases  of  orchitis 
and  epididymitis  during  typhoid  fever  has  been  advanced  by 
Widal  and  supported  by  Hutchinson.  Gwyn^  has  reported  a  case 
which  apparently  supports  this  theory.  Fox"  has  shown  that  focal 
necrosis  of  the  testicle  in  typhoid  fever  is  not  infrequent. 

Gwyn  thinks  that  many  of  the  cases  of  orchitis  or  epididymitis 
occurring  during  typhoid  fever,  in  which  there  is  little  or  no  pain, 
are  caused  by  phlebitis  of  the  veins  supplying  these  parts. 

In  the  first  edition  of  this  essay  we  published  a  table  giving 
a  complete  record  of  all  cases  of  this  condition  which  existed  in  the 
literature  of  that  time  (1898).  Eshner,  who  compiled  the  table, 
found  but  44  cases,  but  since  his  report  so  many  others  have  been 
recorded  that  probably  a  very  small  percentage  of  the  cases  that 
occur  find  their  way  into  medical  literature. 

Alimentary  Tract  and  Associated  Organs  in  Late  Stages 
and  in  Convalescence. — The  affections  of  the  alimentary  canal 
after  typhoid  fever  are  not,  as  a  rule,  of  very  great  importance 
nor  of  great  frequency.  In  the  majority  of  instances  they  consist 
in  more  or  less  severe  signs  of  indigestion  due  to  three  factors, 
namely,  the  inordinate  appetite  of  a  patient  convalescing  from 
typhoid  fever,  which  often  leads  him  to  overload  his  stomach,  his 
inability  to  deal  with  ordinary  amounts  of  food  is  impaired  by  his 

'  Gwyn.     American  Medicine,  February,  1907. 

-  Fox.     Bull.  Ayer  Clin.  Lab.  Pennsylvania  Hospital.  1907,  Xo.  4,  3S. 
14 


210  COMPLICATIOXS  DUniXC  COXVALESCEXCE 

generally  feeble  state,  and,  finally,  the  disordered  condition  of  the 
bowels,  as  represented  by  the  states  of  diarrhaw  or  constipation, 
may  be  prime  factors  in  interfering  with  the  proper  digestion  of 
food. 

Obstinate  and  persistent  constipation  is  the  condition  of 
the  intestine  most  commonly  met  with,  and  it  varies  from  a  moderate 
form  readily  relieved  by  proper  diet  and  drugs  to  a  condition  in 
which  the  fecal  mass  must  be  dug  out  of  the  rectum  with  a  spoon. 
This  condition  is  due  to  two  chief  causes.  In  the  first  place  the 
tissues  are  so  dried  by  the  fever,  so  to  speak,  that  they  eagerly 
absorb  from  the  alimentary  canal  all  the  liquid  they  can  to  restore 
their  normal  moisture;  and,  secondly,  the  prolonged  use  of  a  diet 
leaving  but  little  residue,  and  lack  of  exercise,  is  a  causative  factor 
of  intestinal  atony,  even  if  the  ulceration  and  catarrhal  state  of 
the  mucous  membrane  of  the  bowel  in  the  disease  are  not  con- 
sidered. 

Diarrhoea  may  also  be  a  factor  which  delays  the  patient's  rapid 
return  to  health,  and  it  arises  from  the  use  of  improper  food,  from 
catarrh  of  the  bowels,  or  from  the  presence  of  unhealed  ulcers  in 
the  colon,  or  even  in  the  small  intestine.  This  condition  of  faulty 
healing  of  the  ulcers  in  the  bowel  may  be  a  serious  factor  in  the 
patient's  case.  Rarely,  serpiginous  ulceration  of  the  mucous  mem- 
brane of  the  bowel  is  present,  and  this  results  in  a  persistent  diar- 
rhoea of  a  dysenteric  type,  with,  it  may  be,  loss  of  blood.  This 
condition  has  been  described  by  Jaccoud  in  France,  by  George 
B.  Wood  in  America,  and  by  many  other  clinicians  since  his  time. 

Perforation. — In  other  cases  perforation  of  the  bowel  may  take 
place  with  death  resulting  long  after  the  fever  has  departed.  Thus 
INIorin^  has  recorded  a  case  in  which  perforation  occurred  as  late  as 
the  one  hundred  and  tenth  day.  Sometimes  these  ulcers,  by  afford- 
ing foci  for  septic  infection,  cause  the  maintenance  of  a  low  grade 
of  fever  for  many  weeks.  They  are  not  true  typhoid  ulcers,  but  the 
result  of  profound  necrosis  of  the  intestinal  mucous  membrane 
resultinii'  from  advanced  intestinal  catarrh  and  debilitv. 

Under  the  name  of  diphtheria  of  the  intestinal  mucous  mem- 
brane, Liebermeister  has  described  a  condition  in  which  the  bowel 

'  Morin.     Des  Perforations  Intestinal  clans  le  Cours  de  la  Fiiivre  Typhoide,  Paris,  1869. 


ALIMENTARY   TRACT  IN  CONVALESCENCE  2\\ 

is  affected  by  (lij)li(licr()i(|  sloiiolis.  Very  ran-ly,  if  ever,  ;u'c  iIk-so 
sloughs  truly  diplitlieritic.  The  iilrcintloi)  niidcrlying  tlH-rii  may 
be  severe  enough,  however,  to  rcsiill  in  |)crfor;i(if)ri  of  flic  bf)\vf|, 
as  already  pointed  out. 

Gangrene  of  die  bowel  in  dislinclion  IVoni  \\\rcr:\\]u\]  and  \n(u\ 
necrosis  is  still  more  rai-e.  It  i.s  j)r(jl)ably  due  almost  always,  if 
not  always,  to  thrombosis  or  embolism  of  the  mesenteric  vessels, 
and  in  Hoffmann's  250  cases  at  autopsy  this  lesion  was  found  no 
less  than  nine  times.  In  six  of  these  it  affected  the  ileum,  in  two 
the  vermiform  appendix,  and  in  one  the  sigmoid  flexure.  Those 
cases  in  which  there  is  gangrene  of  the  appendix  are  probably  due 
to  appendicitis,  produced  by  direct  infection  by  the  bacillus  of 
Ebertli  or  by  the  Bacillus  coli  communis.     (See  earlier  chapter.; 

Peritonitis  arising  from  infection  from  the  ulcers  in  the  bowel 
wall  or  from  perforation  may  also  arise  in  this  period  of  the  dis- 
ease. Tschudnowsky^  records  a  case  of  this  character  in  which, 
after  typhoid  fever,  perforation  occurred  with  the  escape  of  gas 
into  the  peritoneal  cavity.  Auscultation  in  this  case  revealed  an 
exquisite  amphoric  murmur  on  inspiration,  due,  it  was  thought,  to 
the  escape  of  gas  through  the  opening  in  the  gut. 

GoodalP  reports  two  cases  of  obstruction  by  peritoneal  adhesions 
following  typhoid.  One  was  in  a  boy,  aged  fourteen  years,  who  was 
convalescing,  when  acute  abdominal  symptoms  developed,  with 
vomiting,  hiccough,  and  pain.  The  symptoms  lasted  several 
days,  and  when  operation  was  finally  performed  the  intestinal 
obstruction  was  located  some  thirty  inches  above  the  ileocaecal 
valve,  and  was  caused  by  a  fibrous  band  of  adhesions,  the  result 
of  an  old  peritonitis  opposite  a  deep  typhoidal  ulcer. 

Cicatricial  contraction  of  the  bowel  due  to  the  healing  of 
the  ulcers  is  an  exceedingly  rare  condition,  which  is  a  curious  fact 
when  we  consider  how  severe  the  ulcerative  process  may  be. 
Young^  has  recorded  a  case,  however,  in  which  the  lower  twenty- 
five  inches  of  the  ileum  were  so  greatly  contracted  that  the  first 
joint  of  the  thumb  could  not  be  inserted  into  the  bowel.     In  this 

1  Tschudnowsky.     Berliner  klin.  Wochenschrift,  1S69,  Xos.  20,  21. 
-  Goodall.     American  Medicine,  May  2,  1902. 

2  Young.     Medical  Press  and  Circular,  18S6,  xlvi,  471. 


212  COMPLICATIOXS  DURIXG  COXVALESCENCE 

case,  too,  about  two  inches  above  the  ileoctvcal  valve  there  was 
constriction,  almost  to  the  ])oint  of  occlusion,  and  a  similar  nar- 
rowing existed  at  the  upper  eml  of  the  ct)ntracted  portion  of  the 
bowel.  AboVe  this  upper  constriction  the  small  bowel  w^as  so 
dilated  that  it  resembled  a  stomach.  The  patient  died  as  the  result 
of  a  fall  from  a  horse  long  after  the  typhoid  attack. 

Concerning  the  more  infrequent  complications  affecting  the 
alimentary  tract  at  this  period,  we  find  a  number  of  interesting 
facts.  Noma  has  been  recorded  in  a  few  cases,  notably  by  Frey- 
muth  and  Petruschky/  wdio  report  a  case  of  noma  of  the  cheek  in 
a  case  of  typhoid  fever  in  which  virulent  diphtheria  bacilli  were 
isolated  from  the  gangrenous  tissue,  and  in  which  healing  follow^ed 
the  use  of  antitoxic  serum.  Keen  collected  nine  cases  in  his  'J'oner 
I^ecture  in  1S76,  although  some  of  these  were  rather  those  of  ulcer- 
ative stomatitis  than  true  noma,  and  Hall  has  reported  to  Keen  a 
case  which,  as  Keen  says,  if  not  one  of  noma  w^as  at  least  akin  to 
it.  The  patient  died  of  hemorrhage  from  the  area  involved  on  the 
thirty-eighth  day  of  the  general  malady.  So,  too,  Littlejohn^  lias 
recorded  two  fatal  cases  of  noma  following  typhoid  fever.  In  one 
of  these  both  cheeks  sloughed;  in  the  other  there  w^as  not  only 
sloughing  of  one  cheek,  but  gangrene  of  the  skin  of  the  hip. 

Sailer^  reports  two  patients,  a  brother  and  sister,  who  during 
the  third  week  of  typhoid  fever  developed  noma.  Klebs-Loeffler 
bacilli  were  found  in  the  necrotic  patches. 

Walsh, ^  in  his  analysis  of  the  statistics  of  Hildebrand  and  Perthus, 
notes  that  noma  followed  typhoid  fever  in  26  of  133  cases  reported 
by  them. 

Aphthous  inflammations  of  the  mouth  may  be  present  in  rare 
cases,  and  is  usually  seen  only  in  patients  who  are  in  crowded 
wards  or  barracks,  in  which  careful  attention  cannot  l)e  paid  to 
individual  cases. 

Glossitis  may  occur  in  typhoid  fever,  but  is  very  rare.     Osier 

1  Freymuth  and  Petruschky.  Deutsche  med.  Wochenschrift ,  1898,  No.  15,  p.  232,  and 
No.  38,  p.  .500. 

2  Littlejohn.     British  Medical  .Journal,  April  30,  1893. 

3  Sailer.     American  .Journal  of  the  Medical  Sciences,  April,  1902. 

^  Walsh.     Proceedings  of  Pathological  Society  of  Philadelphia,  1901,  p.  179. 


A/JM/'JNTAUV    TRACT  IN   CONVA/J-JSC/'JNC/-:  2\'.'> 

has  recorded  a  case  which  developed  ^los.sitis  ten  days  after  his 
temperature  was  normal,  l)ut  recovery  ensnfd  in  ;i  fV-w  d;iy  ;. 

Frankcl'  lias  reported  seven  cases  of  stonialitis  diirin^f  lv|)lii)i(| 
fever,  in  one  of  wlildi  no  .snl)j('('(iv('  syinptoins  were  foiuid. 
M(;('rae''  ajso  re|)orts  three  cases  of  tins  coniplicafion  (jecnrrin^  in 
his  series  of  717  cases  of  typlu^d  fever  at  the  Montreal  (^ieneral 
Hos})ital.  I'rullier''  has  seen  ulceration  of  the  mouth  in  220  cases 
of  typhoid  fever. 

Alveolar  abscess  may  also  occur,  and  Jyiehermeister  records  a 
case  in  which  tiiere  was  emphysema  of  the  cheek  of  the  affected 
side. 

Franklin*  has  reported  a  case  in  which  gangrene  began  in  the 
upper  gum  and  caused  in  five  days  necrosis  of  the  superior 
maxilla. 

A  case  of  gangrene  of  the  mouth  and  partial  necrosis  of  the 
superior  maxillary  bone  has  been  reported  by  WinkouroflP,''  as 
occurring  in  a  little  girl,  aged  six  years.  The  left  cheek  was  observed 
to  be  swollen  on  the  first  day  of  the  illness;  on  the  third  day  a  black 
spot  made  its  appearance  in  the  back  of  the  mouth;  on  the  seventh 
day  the  eschar  suppurated  and  perforation  of  the  cheek  occurred. 
The  most  noteworthy  fact  in  this  case  is  that  of  recovery. 

Induration  followed  by  softening  and  perforation  of  the  cheek, 
and  finally  by  death,  has  been  reported  by  Donald"  as  having 
occurred  in  two  sisters  during  the  course  of  typhoid  fever.  In 
both  cases  the  right  cheek  was  affected.  We  once  had  under  our 
care  a  woman  who,  during  convalescence  from  a  most  grave  attack 
of  typhoid  fever,  developed  an  abscess  in  the  wall  of  the  right 
cheek  which  was  not  connected  with  the  parotid  gland  or  Steno's 
duct. 

Keim^  has  reported  a  fatal  case  of  typhoid  fever  in  a  boy,  aged 
nine  years,  in  which  gangrene  of  the  left  cheek  occurred  during 
convalescence.     Two  other  cases  are  reported  in  the  same  journal. 

1  Frankel.     Deut.  med.  Woch.,  March  20,  1901. 

-  McCrae.     American  iMedicine,  September  26,  1903. 

3  Trullier.     Gaz.  des  Hop.  de  Paris,  1908,  Ixxxi,  207. 

■•  Franklin.     Quoted  by  Hutinel. 

5  Winkouroff.     Bulletin  de  la  Soci^te  Anatomique.  December,  1SS7. 

"  Donald.     London  Lancet,  February  20.  1893. 

'  Keini.     Lehigh  Valley  Medical  Magazine,  October,  1S91. 


214  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

Another  case  has  been  reported  by  Clark,'  in  ^vhi(•h  a  man,  aged 
twenty-eight  years,  suffered  on  the  thirtieth  chiy  of  typhoid  fever 
with  bulging  of  the  right  cheek,  followed  by  closure  of  the  right 
eye  and  great  swelling  of  the  lids,  and  on  the  thirty-third  day  the 
left  eyelids  became  involved,  and  on  the  thirty-fifth  day  large 
non-glandular  swellings  a]i])eared  at  the  angles  of  the  lower  jaw. 
The  right  upper  eyelid  sloughed  away,  and  the  patient  died  of 
exhaustion  on  the  thirty-seventh  day  of  the  illness.  It  is  thought 
that  the  local  condition  was  the  result  of  a  general  infection. 

Sloughing  of  the  face  in  a  child,  aged  twelve  years,  ending  fatally, 
is  reported  by  Ewens.-  In  this  case  the  sloughing  really  followed 
an  attack  of  measles  and  miuiips  which  occurred  during  convales- 
cence in  typhoid  fever. 

Gangrene  of  the  tongue  has  been  reported  once  by  Gaston 
David,^  while  Freudenberger^  has  seen  it  involve  the  uvula.  Spill- 
mann°  met  with  gangrene  of  the  lips  with  final  septicaemia  due  to 
a  secondary  staphylococcus  infection,  which  destroyed  life. 

Liebermeister  records  one  case  of  melanotic  softening  of  the 
oesophagus  after  t^^jhoid  fever. 

(Esophageal  ulceration"  may  lead  in  some  cases  to  stricture.  A 
case  has  been  reported  by  Packard  and  one  by  Mitchell  which 
occurred  in  Osier's  wards.  (See  chapter  on  Well-developed  Stage 
of  the  Disease.) 

A  case  of  ulcer  of  the  oesophagus  has  been  reported  by  Riesman 
to  the  Pathological  Society  of  Philadelphia,  March  9,  1899. 

In  regard  to  lesions  coming  on  at  the  other  end  of  the  alimentary 
canal  after  enteric  fever,  we  find  a  case  of  gangrene  of  the  anus 
reported  to  Keen  by  Betz,  of  Oakville,  Pa.,  the  condition  arising 
in  ail  probability  from  general  thrombosis  of  the  hemorrhoidal 
arteries.  This  patient  was  a  boy,  aged  ten  years,  who  at  the  end 
of  the  fifth  week  complained  of  irritation  about  the  anus,  the  parts 
being  found  slightly  discolored.     ^Yithin  twelve  hours  the  tissues 

1  Clark.     London  Lancet,  April  9,  1893. 

2  Ewens.     London  Lancet,  August  4,  1889. 

3  David.     Quelques  Considerations  sur  la  GaiiKrene  Typhoids,  Thbse  de  Paris,   1887. 
■•  Freudenberger.     Aerztliche  Intelligenzblatt,  1880,  xxvii,  7. 

6  Spillman.     Merc.  ]M(?dicale,  1895,  No.  13,  145. 

6  A  valuable  jiaper,  by  Russell,  on  oesophageal  ulceration  in  general  is  to  be  found  in  the 
Scottish  Medical  and  Surgical  Journal  for  April,  1899. 


AUM/'JNTA/O'   THACT  IN  CONVALEHCENCl':  2 IT, 

of  the  i,sfliior(!(;tal  fossti  sloiif^licfl  out  unci  the  rcftiirn  was  fVjiind 
to  he  gangrenous.  It  ,s|H'e(lily  separafcH,  leaving  a  large  opening. 
Curiously  enough,  al)sohite  recovery  Look  \)\nrc,  the  evacuations 
being  finally  perfectly  controlled. 

Ceases  of  gangrene  of  the  perineum  and  anus  may  occur  from 
extension  of  the  process  from  the  vulva  in  women.  Keen  gives 
interesting  facts  concerning  these  cases  which,  as  they  are  not 
medical  conditions,  are  not  discussed  in  this  hook. 

J'arotitis. — Passing  on  to  the  lesions  found  in  the  cjrgans  asso- 
ciated with  the  alimentary  canal,  we  find  that  inflammation  of  the 
parotid  gland  is  an  unusual  complication  of  typhoifl  fever,  and  is  due 
to  extension  of  infection  from  a  foul  mouth  through  Steno's  duct. 
In  many  instances,  however,  the  parotitis  is  due  to  true  typhoid 
infection.  Thus,  Janowski'  records  a  case  of  a  man,  aged  twenty 
years,  who  (Hed  in  "the  second  or  third  month"  of  the  fever. 
The  bacillus  of  Eberth  was  found  to  be  the  infecting  organism  in 
the  gland.  In  another  case,^  both  the  bacillus  of  Eberth  and  the 
staphylococcus  were  found  to  be  present.  Sometimes  the  inflam- 
matory process  goes  no  farther  than  swelling  and  hyperemia;  in 
others  suppuration  develops,  and  when  it  does  the  destruction  of 
tissue  is  usually  grave,  not  only  in  the  gland,  but  in  nearby  tissues 
as  well.  Curiously  enough,  the  other  salivary  glands  are  almost 
never  affected.  J.  Milton  INIiller^  has,  however,  reported  a  case  of 
typhoid  fever  in  which  there  was  marked  swelling  of  the  sub- 
maxillary glands.  Not  only  may  the  local  necrosis  be  dangerous 
in  itself,  but  if  the  pus  is  not  given  free  vent  it  is  apt  to  burrow 
down  between  the  tissues  of  the  neck  and  cause  septicaemia  -or 
pyaemia  by  infecting  the  great  vessels  and  lymphatics.  Facial 
palsy  may  result  either  from  destruction  of  the  facial  nerve,  by  its 
section  in  incising  the  abscess,  or  by  reason  of  the  pressure  exercised 
upon  the  nerve  as  it  passes  through  the  stylomastoid  foramen,  the 
neighboring  bony  tissues  being  involved.  In  regard  to  the  fre- 
quency of  this  condition,  we  find  that  Hoffmann  met  with  suppiu'a- 
tive  parotitis  in  16  cases  out  of  1600  patients,  and  that  7  of  these  died. 

1  Janowski.     Centralblatt  fiir  Bacteriol.  und  Parasit.,  189.5,  x^■ii.  685. 
-  Lehman.     Centralblatt  fiir  klin.  Med..  August,  1891,  649. 
3  Miller.     University  of  Peuna.  Medical  Magazine,  July,  1899. 


210  COMPLICATIOXS  DURIXG  COXVALESCENCE 

Ordinary  parotitis  occurred  in  3  cases.  In  15  cases  the  attack  was 
liniiteil  to  one  side,  9  times  in  the  right  and  0  times  in  the  left. 
Keen  collected  26  cases  in  his  Toner  Lecture  of  187(5,  and  .")()  more 
in  his  recent  essay.  Thirty  per  cent,  of  these  died,  and  20  of  the 
28  cases  in  which  the  sex  was  named  were  males.  Twenty-nine 
of  his  cases  suppurated  and  only  5  did  not.  In  12  the  trouble  was 
bilateral,  and  7  of  these  suppurated  on  both  sides. 

Parotitis  is  a  lesion  of  the  third  or  fourth  week,  and  is  of  evil 
omen,  since  it  shows  degenerative  changes  in  other  important 
glands. 

Parotitis  was  present  in  45  of  the  2000  Munich  cases  and  in  14 
of  Osier's  1500.  Of  Osier's  14  cases,  5  died.  Hoffmann  noted 
16  cases  of  this  complication  in  1600  typhoid  fever  patients  during 
the  Ba^el  epidemic,  while  Liebermeister  noted  it  6  times  in  210 
fatal  cases  of  this  disease.  Carpenter^  has  recendy  reported  the 
case  of  a  boy,  aged  eleven  years,  who  during  a  severe  case  of 
typhoid  fever  developed  a  double  suppurative  parotitis  on  the 
eighteenth  day  of  his  illness.  On  the  twenty-first  day  of  the  illness 
both  abscesses  were  incised.  From  the  pus  a  bacteriological  study 
revealed  the  presence  of  the  Bacillus  typhosus  as  well  as  the  ]\Iicro- 
coccus  pyogenes  aureus.  This  patient  recovered  after  a  prolonged 
convalescence,  the  incisions  over  the  parotid  glands  closing  on  the 
fifty-first  day  of  the  illness. 

Osier  has  recorded  a  case  in  which  a  right  parotid  abscess  com- 
plicated typhoid  fever  in  a  man  who  was  ill  in  September,  1890. 
In  January,  1896,  when  Osier  saw  him,  he  had  profuse  sweating 
over  the  right  side  of  the  face  and  temple  on  eating,  this  condition 
having  lasted  more  than  five  years.  There  was  no  facial  anaes- 
thesia or  paralysis. 

Hepatic  Lesions. — The  liver  may  become  affected  by  various 
conditions  in  convalescence.  Of  these,  we  find,  as  most  important, 
abscess,  cholangitis,  and  cholecystitis. 

Here,  again,  the  exhaustive  monograph  of  Keen  may  ])e  referred 
to  as  presenting  many  of  the  facts  we  have  concerning  this  organ. 
Abscess  of  the  liver  is  seldom  met  with,  for  Keen  found  only  twenty- 
one  cases  in  literature.     Solitary  abscess  is  due  to  the  Bacillus 

1  Carpenter.     American  Medical  Association,  December  2C,  1908. 


AUMh'NTAIiV   TUACT  IN   CONV ALESCJICSCK  217 

coli  coinmiinis,  to  the  .stapliy!oco(;c;u.s,  or  to  tlic  fjafilliis  of  Khfrtli, 
and  is  very  rare.  O.slcr  states  that  this  complication  occurred  in 
three  of  his  829  cases,  and  it  was  observed  to  have  more  fre(|iMiitly 
followed  such  complications  as  [jarotilis  or  necrosis  of  Ijonc.  J.  M. 
Da  Costa  collected  22  cases  in  which  the  assfjcijilion  of  iihscess  of  the 
liver  with  ty[)hoid  fever  seemed  heyond  doiiiif.  Of  these  cases, 
only  seven  were  jjiundiecd.  In  2()()()  jiiitopsics'  upon  typhoid  ffver 
subjects  at  Munich  abscess  of  the  liver  was  met  with  but  12  times, 
while  Dopfer,  in  927  cases,  found  abscess  formation  present  in  10. 
It  is  of  interest  to  note  that  of  the  21  cases  of  solitary  abscess 
collected  by  Keen,  19  died.  Thomas,^  in  a  recent  review  f>f  the 
literature,  was  able  to  find  but  2<S  authenticated  c-ases  of  hepatic 
abscess  which  occurred  as  a  complication  to  or  a  sequel  of  typhoid 
fever. 

Three  modes  by  which  hepatic  abscess  develops  have  been 
described:  (1)  As  one  of  the  manifestations  of  general  secondary 
septicajmia  or  pyaemia  complicating  typhoid  fever;  (2)  as  a  result 
of  septic  pylethrombosis,  in  connection  with  suppurative  affections 
of  the  intestine,  especially  the  caecum;  (3)  in  consequence  of  various 
inflammatory  and  ulcerative  processes  in  the  large  biliary  passages 
and  in  the  gall-bladder.  Curschmann  has  reported  instances  of  all 
three  modes  of  origin. 

When  there  are  septic  foci  elsewhere  the  abscess  is  usually 
secondary  and  multiple.  Louis  has  recorded  a  case  of  hepatic 
abscess  associated  with  parotid  suppuration,  and  Chvostek  one 
consecutive  to  perichondritis  of  the  larynx.  Delaire^  has  reported 
an  instance  in  which  a  hepatic  abscess  ruptured  into  a  bronchus; 
the  abscess  was  incised  and  recovery  occiu-red. 

Lannois  reports  the  following  case,  wliich  occurred  in  the  Hopi- 
tal  ]\Iilitaire  de  la  Charite  in  1881 :  A  man,  aged  twenty-two  years, 
after  several  days  of  malaise,  presented  all  the  signs  of  adynamic 
enteric  fever.  In  the  third  week  be  became  intensely  jaundiced, 
"fairly  black;"  the  liver  was  enlarged;  there  was  active  delirium 
and  intense  pulmonary  congestion.     Eleven  days  after  the  onset 

1  Holscher.     Miinclienermed.  Wochenschrift,  1S91,  Xos.  3  and  4. 
-  Thomas.     New  York  Medical  Journal.  October  12,  1907. 
^  Delaire.     Gazette  des  Hopitaux,  1S69. 


21S  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

of  the  jauiulice  a  small  sujierficial  abscess  appeared  on  the 
back  of  the  left  hand  and  on  the  right  side  of  the  face.  The 
antopsv  revealed  the  ordinary  lesions  of  typhoid  fever,  congestion 
of  the  Inngs,  and  an  enorinons  hepatic  abscess  of  3000  grams 
(3  quarts).  The  pus  was  yellow  anti  greasy,  and  the  gall-bladder 
was  distended  with  clear  liquid  and  mucopus.  The  other  case 
recorded  by  Lannois^  is  somewhat  different  from  this,  in  that  the 
symptoms  of  abscess  developed  after  the  fever  had  ceased.  On 
the  third  day  of  apyrexia  the  patient,  who  was  a  young  man,  aged 
twenty-eight  years,  was  seized  by  a  violent  chill,  followed  by  high 
fever  and  at  the  same  time  by  signs  of  "  pleuropulmonary"  dis- 
ease at  both  bases,  but  chiefly  at  the  right  base.  Ten  days  later 
the  belly  was  tympanitic,  and  there  was  tenderness  in  the  hypo- 
chondrium  of  the  right  side.  Rapid  emaciation  ensued;  the  pulse 
became  feeble,  and  the  patient  oppressed.  Sharp  pain  was  suffered 
in  the  epigastrium.  There  was  no  oedema  or  albuminuria.  The 
autopsy  revealed  old  lesions  of  enteric  fever,  and  in  the  vena  porta 
a  large  thrombus  which  extended  into  all  the  neighboring  branches. 
Ten  large  abscesses  were  found  in  the  lower  part  of  the  right  lobe 
of  the  liver.  They  varied  in  size  from  a  mandarin  orange  to 
that  of  an  egg.  The  pus  was  creamy  yellow.  Pleural  effusion 
was  present. 

Ehrlich^  describes  a  case  of  unmistakable  typhoid  infection  in 
which  the  characteristic  lesions  were  absent  from  the  intestine,  but 
cultures  from  the  biliary  passages  and  liver  revealed  a  pure  culture 
of  Bacillus  typhosus.  He  gave  the  name  septic  typhoid  cholangitis 
to  this  condition. 

Barlow^  reports  a  patient,  aged  fifty-nine  years,  who  suffered 
with  biliary  colic  followed  by  jaundice  and  cholecystitis.  From 
the  gall-bladder  and  heart's  blood  were  isolated  typhoid  bacilli. 
The  same  author  also  reports  six  other  cases  in  which  without 
previous  symptoms  of  the  disease,  cholecystitis  was  present  and  a 
culture  from  the  bile  revealed  typhoid  bacilli.     Jundel^  reports  an 

1  Lannoi.-;.  Revue  de  Mc'decine,  1895,  p.  913;  Pylcjphldbite  et  AbscL-s  de  Foie  Cons(:-cutif 
&  la  Fievre  Typhoide. 

-  Ehrlich.     Deut.  med.  Woch.,  Berlin  and  Leipzig,  December,  1906. 

3  Barlow.     Medicine,  October,  1903. 

*  Jundel.     Hygiea  Stockholm,  February,  1903. 


ALIMENT  Alt)'   Tit  ACT  IN   CVN\'ALI-JSCI'JNCI'J  210 

instance  of  typlioid  inrcction  (<f  (Ik;  {full-Madflf-r  vvlicrf;  typhoir] 
bacilli  were  foiiiid  in  tlic  ccnlrcs  of  the  gallstones,  while  Krarncr' 
mentions  an  instance  of  snppiirative  cholecystitis  ,'is  ;in  innnefliute 
se((uel  (o  typhoid  fever.  Tlie  |eiiipei;i  lure  li;id  only  heen  norni;d 
a  few  days  when  it  rose  as  the  result  of  the  g;ill-M;idder  infection, 
which  when  operated  upon  revealed  a  gall-hladder  full  of  pu.s. 
This  was  evacuated  with  35  gallstones,  from  the  centre  of  which 
typhoid  hacilli  were  isolated.  It  is  of  interest  to  note  that  Osier 
found  hut  19  cases  of  cholecystitis  in  his  series  of  1500  cases. 

Multiple  abscesses  of  the  liver  have  been  recorded  })y  Romberg^ 
after  a  severe  attack  of  typhoid  fever  complicated  by  hemorrhage 
and  followed  by  jaundice;  death  occurred.  ^Miliary  abscesses  were 
scattered  through  the  liver  in  large  numbers,  and  there  was  sup- 
puration of  the  mesenteric  glands  with  thrombosis  of  the  portal 
vein  and  its  branches. 

Another  case  of  multiple  hepatic  abscess  complicating  convales- 
cence in  typhoid  fever,  has  been  reported  by  Herman,^  of 
Memphis.  The  patient  was  a  man,  aged  twenty-six  years,  a  fire- 
man by  occupation,  who  on  the  thirty- third  day  of  his  illness  was 
seized  with  a  chill  and  severe  lancinating  pain  in  his  right  side, 
followed  by  a  rise  in  temperature  and  marked  tenderness  in  the 
liver,  but  no  physical  signs  of  pulmonary  trouble.  Three  days  later 
the  patient  suffered  from  rigors  and  sweats.  An  aspirator  revealed 
pus,  and  upon  the  ninth  rib  being  resected,  six  ounces  of  chocolate- 
colored  pus  escaped.  Later,  another  rise  in  temperature  with 
sweats  indicated  the  presence  of  f mother  pus-formation,  and  explo- 
ration revealed  additional  abscesses  which  discharged  pus  when 
their  walls  were  broken  down  by  the  finger  of  the  operator.  Tliis 
happened  a  third  time,  and  in  each  instance  when  the  pus  was 
evacuated  temporary  improvement  took  place,  but  the  patient 
finally  died  from  exhaustion. 

Suppurative  pylephlebitis  is  another  rare  state,  but  is  more 
frequent  than  is  abscess  of  the  liver.  It  may  follow  perforation  of 
the  appendix  and  may  cause  hepatic  abscess.     It  arises  usually 


1  Kramer.     Medical  News,  May,  1905. 

-  Romberg.     Berliuer  klin.  Woclienschrift,  March  3,  1891. 

3  Herman.     Memphis  Lancet,  1899. 


220  COMPLICATIO.XS  DrHlXa  cow  ALESCEXCE 

as  the  result  of  thrombosis  of  the  vena  porta.  Schultz  found,  in 
studying  the  statistics  of  3G86  cases  of  typhoid  fever  in  Hamburg, 
that  302  deaths  occurred,  but  no  instance  of  this  condition  was  met 
witli.  BuckHng*  found  this  lesion  in  two  cases.  Romberg,'  who 
studied  ()77  cases,  with  SS  deatlis,  found  but  one  instance,  although 
he  refers  to  four  more.  Staphylococci  were  found  in  the  thrombi 
and  in  the  pus.  Osler^  saw  one  case  in  which  multiple  abscess  of 
the  mesentery  was  present,  and  the  portal  vein  outside  of  the  liver 
was  an  elongated  abscess.  So,  too,  Lannois"*  records  a  case  of 
thrombosis  of  the  portal,  splenic,  and  inferior  mesenteric  veins, 
with  multiple  hepatic  abscesses.  In  this  case  the  specific  bacillus 
was  found  in  the  pus.  Klebs""  has  recorded  a  case  of  suppurative 
cholangitis  in  which  the  bile  passages  were  dilated  into  large  abscess 
cavities. 

Cholecystitis,  unlike  the  true  hepatic  complications  of  typhoid 
fever  just  considered,  is  as  common  as  they  are  rare. 

Andral  and  GrisoUe  wrote  about  it  as  long  ago  as  1S35,  and 
later  Rokitansky,"  Frerichs,^  and  Budd*^  recorded  such  cases.  In 
America  as  long  ago  as  1846  Ayres"  reported  the  case  of  a  young 
physician  so  affected,  who  died  of  peritonitis,  and  jNIurchison^" 
tells  us  that  "fatal  peritonitis  may  result  from  ulceration  of  the 
gall-bladder  proceeding  to  perforation." 

Although  as  long  ago  as  1836  Louis"  called  attention  to  the  fact 
that  changes  in  the  bile  passages  and  in  the  gall-bladder  occurred 
more  frequently  in  the  course  of,  or  following,  typhoid  fever  than 
in  any  other  disease,  Fiitterer,  in  1888,  was  the  first  to  isolate  the 
Bacillus  typhosus  from  the  gall-bladder.  It  was  not  until  1890  that 
Gilbert  and  Girode^"  proved  that  suppurative  cholecystitis  arose 

'  Buckling.  Falle  von  Leber  Absoesse,  Berlin,  1868. 
-  Romberg.  Berlin,  klin.  Wochenschrift,  1890,  192. 
'  Osier.     Tran."*.  .\ssoo.  American  Physicians,  1897,  382. 

*  Lannois.     Revue  de  M(?decine,  1895,  909. 
'  Klebs.     Handbuch  der  Pathol.  Anatomie. 

^  Rokitansky.     Manual  of  Path.  Anat.,  Sydenham  translation,  ii,  160. 
"  Frericlis.     Diseases  of  Liver,  ii,  454,  Sydenham  translation. 

*  Budd.     Di.seases  of  Liver,  .3d  American  ed.,  Philadelphia,  1857. 
'  Ayres.     New  York  Journal  of  Mctlicine,  1846,  vii,  315. 

'"  Murchison.     Continued  Fevers  of  Great  Britain,  pp.  566  and  634. 
1'  Louis.     Typhoid  Fever,  Trans.  Bigelow,  1836,  i,  269. 

'=  Gilbert  and  Girode.     M(«m.  de  la  Socic'-td  de  Biol.,  1890;  La  Semaine  Mdd.,'l890,  No.  58, 
and  Mdm.  de  la  Socidtd  de  Biol.,  1893,  p.  986. 


AIJM/'JNTAUY    Th'ACT  IN   CON V ALESCHNCh:  221 

from  iyplioid  iiilCclion.  .\;iiiii\ii'  nlxiiit  tlic  .-.;iiii'-  liiiic  l)roii;.'lit 
forw.inl  liis  tlicoi-y  tliut  f^allstoncs  were  (Jiic  to  the  futarilial 
inflaiiiHiatioM  iiuliicod  by  the  prescnre  of  rnifrf>-or^'anisrri.s,  hut 
his  report  did  not  deal  with  the  particiihir  \\\\\\\^^\\(^^•  of  the  haeillns 
typhosus  as  a  causative  factor  of  such  iiiflaininatious. 

The  importance  of  a  history  of  a  previous  attack  of  ty}>hoid 
fever  vv^hen  making  a  diagnosis  of  cholecystitis  is  always  to  Ije 
remembered,  for  a  large  numJ)er  of  cases  are  now  ow  rcffjrd  in 
which  typhoid  bacilli  in  pure  culture  have  been  isohited  from  gall- 
bladders which  were  afiected  by  cholecystitis  a  few  weeks  or  as 
long  as  twenty-five  years  after  an  attack  of  typhoid  fever.  Not 
infrequently  other  bacteria,  particularly  the  bacillus  coli  com- 
munis, are  discovered  in  the  gall-bladder  with  or  without  the 
bacillus  typhosus. 

It  has  also  been  proved  that  the  bacillus  of  Eberth  may  remain 
for  many  months  in  the  gall-bladder  before  it  produces  grave 
disorders.  Thus,  Dupre^  records  a  case  in  which,  at  a  chole- 
cystotomy,  the  bacilli  were  found  in  the  gall-bladder  six  months 
after  the  fever  ceased,  and  Chantemesse^  records  such  an  instance 
eight  months  after  the  fever,  while  von  Dungen*  recites  one 
remarkable  instance  of  cholecystitis  fom*teen  and  a  half  years 
after  the  fever.  In  the  pus  of  this  case  the  Eherth  bacillus  was 
found. 

The  American  writers  on  this  topic  have  been  chiefly  Mason, '^  of 
Boston,  and  Osier."  Pratt,^  Gushing,^  Richardson,"  Mitchell,^*^ 
Stockton  and  Lyte,^^  Burley,^^  Stewart,^^  Kelly,"  and  AYilson^' 
have  all  reported  cases  of  this  condition.     Mason  tells  us  that  the 

'  Naunyn.     XI  Congress  fiir  inner.  Medicin,  Weisbaden,  1891. 

^  Dupr^.     Les  Infections  Biliares.     Tlifese  de  Paris,  1891. 

3  Chantemesse.     Traite  de  Med.,  i,  764. 

^  Von  Dungen.     Jliinchener  med.  Wochenschrift,  1897,  No.  26,  699. 

5  Mason.     Transactions  Assoc.  American  Phys.,  1897,  xii,  23. 

6  Osier.     Ibid.,  p.  378. 

^  Pratt.     Amer.  Journ.  of  Med.  Sciences,  November,  1901. 

s  Cushing.     Johns  Hopkins  Hosp.  Bull..  1898,  ix.  91. 

^  Richardson.     Boston  Med.  and  Surg.  Journ.,  December  2,  1897. 
10  Mitchell.     Maryland  Med.  Journ.,  1901,  xliv,  13. 
"  Stockton  and  Lyte.     New  York  State  Journal  of  Med.,  1902,  ii,  232. 

12  Burley.     Am.  Med.,  October,  1903. 

13  Stew-art.     Am.  Med.,  190-1,  vii.  1019. 

"  Kelly.     Am.  Jour,  of  Med.  Sci.,  September,  1906. 

15  Wilson.     Journ.  of  Amer.  Med.  Assoc,  May  16,  1908. 


222  COMPLICATIOXS  DURIXG  COXVALESCENCE 

records  of  the  Boston  City  Hospital  show  only  three  cases  of  this 
character  other  than  his  own.  Two  of  these  died.  His  own  case 
recovered  after  the  gall-bladder  had  been  tapped. 

A  case  has  been  recorded  by  Anderson*  in  a  man,  aged  sixty-seven 
years,  who,  two  months  after  typhoid  fever,  was  seized  with  intense 
pain  in  the  right  hypochondrium,  followed  by  death  in  ten  days. 
The  autopsy  revealed  peritonitis  and  perforation  of  the  gall- 
bladder due  to  the  bacillus  of  Eberth  or  the  Bacillus  coli  com- 
munis. Alexieef"  also  reports  a  case  in  which  a  child,  aged  five 
years,  sutt'ered  from  a  pear-shaped  tumor  in  the  hepatic  area,  and 
great  pain.  Operation  revealed  suppurative  cholecystitis,  with  the 
typhoid  bacillus  in  the  pus;  recovery  occurred.  Hawkins'  reports 
a  case  of  this  character  in  which  after  death  there  were  found 
typhoid  lesions,  and  Osler^  records  four  cases,  three  of  which 
recovered  and  one  died.  He  also  records  two  cases  of  hepatic  colic,  > 
one  of  which  followed  enteric  fever,  and  one  which  had  typhoid 
bacilli  in  the  gall-bladder  without  having  had  typhoid  fever. 

Gushing  has  also  reported  in  the  Johns  Hopkins  Hospital 
Bulletin  for  May,  1898,  a  case,  in  which  cholecystotomy  was 
performed  for  a  cholecystitis,  in  which  the  typhoid  bacillus  was 
foimd,  although  there  was  no  history  of  typhoid  fever.  The 
blood  in  Cushing's  case  also  gave  the  typhoid  reaction. 

The  diagnosis  of  gall-bladder  infection  rests  on  the  following 
points:  Tenderness  on  pressure  a  little  above  and  to  the  right  of 
the  umbilicus.  There  is  pain  in  the  gall-bladder  and  under  the 
scapula,  and  often  a  pear-shaped  mass  can  be  detected  in  the  ante- 
rior hypochondrium.  This  may  fluctuate.  If  perforation  occurs 
peritonitis  speedily  develops.  As  Mason  well  says,  in  diagnosis 
we  must  exclude  impacted  feces,  hydronephrosis,  cyst,  displaced 
kidney,  and  appendicitis,  and  when  rupture  of  the  gall-bladder 
has  occurred,  intestinal  perforation.  Leukocytosis  would  be  indic- 
ative of  acute  cholecystitis  and  appendicitis. 

The  prognosis  of  cholecystitis  is  grave.     Only  one-quarter  of  the 

'  Anderson.     Canada  Lancet,  1896. 

-  .\lexieef.     Quoted  by  Osier,  ibid. 

3  Hawkins.     Lancet,  January  30,  1897.  '  Ibid. 


ALIMENTARY   TRACT  IN   COW  A  LKSCHNCh:  223 

cases  collected  })y  Mjison  ^ui  well.  'V\u-  morlalily  of  \)cy\iiyu- 
tion  of  the  f^Jill-hliulder  is  very  lii^li.  'i'vveiity-six  ca.se.s  iioi  (.[xi- 
ated  oil  died;  of  four  operated  on,  (liree  recovered  ancJ  (jue  died. 
For  further  statistics  the  reader  is  referred  lo  Keen's  essay. 

A  most  iiiterestiuf^  and  detailed  aceoiint  of  an  extensive  investi- 
gation as  to  the  <'tiologieal  factor  in  a  household  (-[jirh-inic  of 
typhoid  fever  was  read  by  George  A.  Soper  hefore  (Im-  liiolrtgjfjil 
Society  at  Washington,  D.  C,  on  April  6,  1907.  Careful  examina- 
tion excluded  Uie  water,  milk,  vegetables,  fruit,  and  shellfish  as 
possible  sources.  There  were  no  cases  in  the  town  iinmcdiately 
preceding  or  following  those  cases  studied,  and  none  of  the 
patients  had  been  away  for  several  weeks  before  they  fell  sick,  so 
that  there  could  be  no  question  but  that  the  disease  had  been 
acquired  on  the  premises,  which,  however,  were  in  a  thoroughly 
hygienic  condition.  On  August  4  a  new  cook  was  received  into 
the  family,  and  had  been  with  them  for  three  weeks  before  and 
three  after  the  outbreak.  An  investigation  of  her  career  showed 
that,  although  the  record  for  nearly  two  of  the  past  five  years  has 
not  yet  been  completed,  twenty-six  cases  of  typhoid,  including 
one  death,  were  associated  with  her  services  in  seven  families, 
scattered  from  Maine  to  New  York,  during  this  time.  Indirect 
information  indicated  that  she  herself  had  suffered  a  mild  attack. 
Examination  of  the  stools  revealed  the  presence  of  large  numbers 
of  typhoid  bacilli,  and  the  blood  gave  a  positive  reaction  to  the 
agglutination  test. 

One  of  the  most  important  discoveries  concerning  typhoid  fever 
since  the  first  edition  of  this  essay  was  published  was  the  discovery 
of  the  fact  that  patients  harbored  in  their  gall-bladders  the  specific 
organism  of  the  disease  long  after  the  original  attack  of  the  disease. 
Lentz*  termed  those  patients  from  whom  the  organism  could  be 
isolated  ten  weeks  after  the  onset  of  the  attack  or  after  a  relapse, 
"bacillentrager"  or  bacillus  "carriers."  He  collected  ninety-eight 
such  cases  from  seven  sanitary  stations  in  Germany,  and  thinks 
that  about  4  per  cent,  of  cases  of  typhoid  become  "carriers."     In 

1  Lentz.     Klin.  Jahrbuch,  1905,  vol.  xiv,  p.  475. 


1 


224  COMPLICATIOXS   DrRIM;  COXVALESCEXCE 

one  case  the  organism  was  isolated  t'loni  the  stools  twelve  years 
after  the  attack  of  typhoid  fever. 

Since  the  first  dis(t)very  and  reporting  of  these  cases  of  "car- 
riers of  infection,"  many  cases  have  been  discovered,  and  withont 
donbt  many  household  epidemics  of  the  past  have  l)C('n  due  to  the 
agency  of  these  "carriers." 

Dehler^  was  the  first  to  report  an  operation  for  draining  the 
gall-bladder  for  the  prevention  of  any  fuitlicr  dissemination  of 
tvphoid  bacilli  in  the  stools.  Since  his  report  many  other  surgeons 
have  performed  similar  operations. 

Cholelithiasis. — Bernheim  was  the  first  to  draw  attention  to 
the  direct  relation  between  typhoid  fever  and  gallstones,  but 
"Welch-  was  the  first  to  discover  the  typhoid  bacillus  in  the 
nucleus  of  a  gallstone.  Fournier,^  in  his  studies  of  100  biliary 
calculi  removed  at  autopsy,  found  living  or  dead  bacteria  in 
3S  per  cent,  of  these  formations.  Pratt^  examined  17  concretions, 
and  found  that  foiu"  contained  the  bacillus  typhosus;  and  Funke,'"' 
who  examined  102  calculi,  found  that  31  gave  a  growth  upon  media, 
while  71  inoculations  remained  sterile.  In  this  series  of  cases  the 
Bacillus  typhosus  was  found  but  once,  while  a  pure  culture  of 
colon  bacillus  was  found  1 1  times. 

Dufourt"  has  recorded  nineteen  cases  of  biliary  lithiasis  w'hich 
had  their  first  attacks  after  enteric  fever  and  all  of  them  within 
ten  months  of  the  fever.  Gilbert  and  Fournier^  divide  typhoid 
cholelithiasis  into  two  groups :  those  which  are  the  more  numerous, 
being  due  to  the  colon  bacillus,  and  the  less  frequent  form,  due 
to  the  bacillus  of  typhoid  fever. 

Cushing*^  tells  us  that  a  prior  history  of  typhoid  fever  is  often  met 
with  in  gallstone  cases  in  Halsted's  clinic  at  Baltimore:  and  that 
it  occurs  in  the  proportion  of  10  in  31  cases.     Hektoen"  also  tells 

1  Dehler.     Miinchener  medizinische  Woclienschrift,  April  16,  1907. 

2  Welch  and  Blackstein.     Johns  Hopkins  Hosp.  Bull.  July,  1891. 
'  Fournier.     Compt.  rend,  de  la.  Soc.  biol.,  October  30,  1897. 

■•  Pratt.     Am.  Jour.  Med.  Sciences,   1901,  cx.xii,  p.  584. 

'  Funke.     Proceedings  of  the  Pathological  Society  of  Philadelphia,  1908,  xi.  No.  1. 

8  Dufourt.     Revue  de  M6d.,  Paris,  1893,  p.  247. 

'  Gilbert  and  Fournier.     Compte  rendus  Soc.  Biol.,  March  5,  1897,  p.  93G. 

8  Gushing.     Johns  Hopkins  Hospital  Bulletin,  May,  1898,  No.  86. 

*  Hektoen.     Progressive  Medicine,  March,  1899. 


ALIM/'JNTAUr  TRACT  IN  CONVALI::SCJ'JNCE  225 

us  that  he  has  recently  seen  a  ease  in  whifli  lli'-  [>m  ;  fioni  ;i  ii|>- 
purative  lithiasis  of  the  gall-blad(Jer  gave  tlie  W  i<ial  j(;uli(;n.  'J  Jii.s 
patient  had  typhoid  fever  six  years  l)efore.  C'ushing  suggests 
that  the  typhoid  bacilli  cnlci-  iIh-  n;,||-M;i(J(|(r,  ;is  they  have  been 
shown  to  do  by  Fiitterer,'  and  remain  alive  a  long  time,  during 
which  an  agglutinative  reaction  takes  })lace,  forrrn'ng  a  eliiin|> 
about  which  the  material  for  the  fornuifion  of  a  stone  clusters. 

Abdominal  I.ymph  Nodes. — The  mesenteric  and  retroperitoneal 
glands  may  undergo  suppuration  and  cause  sepsis.  In  other 
instances  a  subdiaphragmatic  abscess  forms  because  of  flK>- 
lecystitis,  of  suppuration  of  these  glands,  or  from  perforation  of 
the  bowel.  A  case  of  this  character  is  recorded  by  Klein'  of  left- 
sided  subphrenic  abscess  due  to  typhoid  fever,  in  which  the  pus 
contained  the  specific  bacillus.  Three  liters  of  pus  were  allowed 
to  escape  by  incision.  The  patient  recovered.  Keen  tells  us  that 
this  is  the  only  case  he  could  find  in  literature. 

TungeF  reports  a  very  interesting  case  in  which  a  suppurating 
mesenteric  gland  near  the  caecum  caused  perforation  of  the  supe- 
rior mesenteric  artery  and  death  from  hemorrhage. 

Lehman^  records  a  case  of  suppurating  mesenteric  gland,  the 
pus  of  which  contained  the  bacillus  of  Eberth,  and  Frankel' 
reports  a  case  of  abscess  in  the  abdomen  due  to  this  cause  four 
and  a  half  months  after  the  fever.  The  specific  bacillus  was  found 
in  this  pus  also. 

Other  cases  have  been  reported  by  Michie,"  Thomson,"  and 
Low.^ 

J.  H.  Bryant''  reports  a  case  wliich  at  autopsy  showed  no 
intestinal  lesions,  but  the  mesenteric  glands  were  engorged  \\'ith 
typhoid  bacilli.     He  was  able  to  find  in  the  literature  fifteen  similar 

1  Fiitterer.     Munchener  med.  Wochenschrift,  1888,  No.  19. 

"  Klein.  Ueber  die  Pyogene  Wirking  des  Eberthschen  Bacillus  bei  TjiDliuskomplicationen, 
Inaug.  Dissert.,  Bonn,  1898. 

^  Tungel.    Klin.  Mittheil.  aus  der  Kaiserlich.,  Hamburg  Allegemeine  Krankenliaus,  1864. 

^  Lehman.      Centralblatt  fiir  klin.  Med.,  August,  1891,  649. 

'  Frankel.     Verhandl.  Kongress  fiir  inner  Med.,  1887,  179. 

6  Micliie.     British  Medical  Journal,  1888,  i,  1388. 

'  Thomson.     Glasgow  Medical  Journal,  1882,  xvii,  244. 

8  Low.     British  Medical  Journal,  ISSl,  ii,  122. 

9J.  H.Bryant.     British  Medical  Journal,  April  1,  1899. 

15 


226  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

cases,  wliile  Lartigan'  adtls  to  tliis  mnnl)er  one  other  case  seen 
by  him. 

Jaundice  following  tyj)li()i(l  fever  is  exceedingly  rare.  Of  the 
2000  cases  of  typhoid  at  Munich  reported  by  Holscher,  this  com- 
plication occurred  22  times.  Liebermeister  met  with  it  twenty 
times  in  1420  cases,  Griesinger  ten  times  in  GOO  cases,  Osier  not 
once  in  one  series  of  500  cases.  Murchison  saw  only  three  cases, 
all  of  which  were  fatal.  It  is  caused  by  catarrh  of  the  ducts, 
toxaemia,  abscess,  and  gallstones  with  or  without  cholangitis. 
Osier,"  however,  records  two  cases,  in  one  of  which  the  jaundice 
developetl  at  the  onset  of  a  relapse,  in  the  other  at  the  end  of 
the  second  week.  The  first  case  recovered,  the  second  died  of 
toxamiia. 

Another  case  of  Jaccoud's,  studied  by  Sabourin,^  was  that  of  a 
man,  aged  twenty-nine  years,  in  the  third  week  of  the  disease,  who 
had  intense  icterus,  great  asthenia  and  delirium.  Death  ensued, 
and  at  the  autopsy  the  lesions  of  typhoid  fever  were  found 
associated  with  a  condition  of  the  liver  resembling  acute  yellow 
atrophy  of  this  organ. 

Da  Costa'  made  a  careful  analysis  of  52  cases,  of  which  33  died. 
As  nearly  as  could  be  determined,  the  cause  of  the  jaundice  was 
catarrhal  inflammation  in  4,  pylephlebitis  in  3,  cholecystitis  in  5, 
abscess  in  6,  acute  yellow  atrophy  in  5,  toxic  in  24,  and  uncertain 
causes  in  5.  Dr.  Warren  Coleman'^  reports  a  case  complicated  by 
jaundice  in  the  prodromal  period,  while  Ogilvie®  reports  four  cases 
coming  on  during  the  course  of  the  disease.  It  is  interesting  to 
note  that  Hamilton'  states,  in  his  excellent  account  of  an  epidemic  of 
tj'phoid  in  an  insane  asylum  in  which  27  patients  over  fifty  years 
of  age  were  studied,  that  there  were  three  patients  with  symptoms  of 
cholecystitis,  all  of  whom  had  jaundice. 

In  the  tropics,  jaundice  seems  to  be  a  more  frequent  complica- 

1  Lartigan.     Johns  Hopkins  Bulletin,  April,  1899. 

2  Osier.       Loc.  cit. 

3  Sabourin.     Re^'ue  de  M6d.,  1882,  ii,  600. 

*  Da  Costa.     American  .Journal  Medical  Sciences.  July,  1898. 

^  Warren  Coleman.     New  York  Academy  of  Medicine,  January  10,  1906. 

0  Ogilvie.     British  Medical  Journal,  January  12,  1901. 

'  Hamilton.     American  Journal  Medical  .Sciences,  October,  1907. 


AfjM/'JNTAR)'  TL'Acr  IS  COS V ALi:s(;i-:x(:r: 


997 


don  of    l\|)lioi(|    fcvci'    lli;iii    in    (he  (cinpctMlc  zoiic,   for  .I;iiiiic^oii' 
records  iiiiie  cji.scs,  ot"  wliicli  Umv  diod. 

Si'LKNiC  TiKsroNS.  Soiiicfimcs  l)_v[)f'rlroj)liif  (■iil;ir<;cm<-iil  r,!'  die 
spleen  occurs  aflcr  (yplioid  lexer.  VV(;  have  seen  two  cases;  (lie 
enlar(^'cmcii(   in  one  case  is  illiistralcd  in  \'\ii.  2').     Tlicre  were  wo 

Fio.    25 


n 


Splenic  enlargement  after  tjishoid  fever. 

blood  changes,  and  no  history  of  malarial  infection  was  obtained 
in  this  case. 

A  number  of  cases  of  rupture  of  the  spleen  due  to  the  develop- 
ment of  an  abscess,  and  later  exposure  and  traumatism,  have 
been  recorded  during  convalescence  in  typhoid  fever.      Harrington" 


1  Jamieson.     Imperial  Maritime  Customs  Med.  Reports,  1S91,  37th  issue. 
-  Harrington.     Lancet,  1905,  p.  1398. 


228  COMPLICATIOXS  DVBING  COXVALESCEXCE 

reports  two  cases  of  abscess  of  the  spleen  clurinp;  typlioid :  one  founti 
post  mortem  and  one  operated  upon.  Federmami^  in  the  same 
journal  reports  an  instance  of  abscess  of  the  spleen  wliicli  com- 
plicated convalescence.  Biron-  reports  a  similar  case.  A  case  of 
rupture  of  the  spleen,  not  due  to  these  causes,  is,  however,  reported 
bv  Santi  Flavio.'  A  man,  aged  twenty  years,  after  having  been 
under  observation  for  ten  days,  sutt'ering  from  typhoid  fever,  devel- 
oped pleural  pneumonia  with  pleural  effusion,  which  required  ta{> 
ping.  Two  months  later  the  patient  suffered  from  severe  pain  in 
the  left  hypochondrium,  the  action  of  the  heart  became  rapid  and 
feeble,  and  oedema  of  the  left  leg  was  present.  After  a  brief 
period  of  improvement  the  patient  was  suddenly  seized  with  peri- 
tonitis and  died,  and  the  autopsy  showed  that  in  addition  to  the 
peritonitis  there  had  been  rupture  of  the  spleen,  and  that  the  pus 
which  it  contained  had  been  diffused  throughout  the  entire  perito- 
neal cavity.  A  recent  infarction  was  found  in  the  neighborhood 
of  the  rupture,  and  the  intestines  showed  evidences  of  an  old 
typhoid  fever.  It  is  not  certain  that  this  splenic  abscess  was  due 
to  the  typhoid  fever. 

Foreign  Body  ix  the  Bow^el. — As  an  illustration  of  what  a 
patient  can  recover  from  during  typhoid  fever,  in  the  way  of  an 
accident  extrinsic  to  his  disease,  Heath^  cites  the  case  of  a  man, 
aged  twenty-tliree  years,  who  at  the  end  of  the  fourth  week  of  his 
fever  swallowed  a  clinical  thermometer.  A  mustard  emetic  failed 
to  bring  away  the  thermometer,  nor  did  a  castor  oil  purge  cause 
its  discharge  from  the  bowel,  but  twelve  days  after  it  had  been 
swallowed  it  w'as  passed  unbroken  and  registered  a  temperature  of 
104.7°. 

Nervous  Symptoms  in  the  Far-advanced  Stage  of  the  Disease 
or  following  Typhoid  Fever. — Paralysis  complicating  typhoid 
fever  or  its  convalescence  may  occur  in  a  number  of  forms,  just  as 
paralysis  may  occur  from  lesions  due  to  other  causes. 

It  may  occur  as  a  local  paralysis  or  monoplegia,  as  a  general 

'  Federmann.     Lancet,  1905,  p.  1398. 

2  Biron.     Vratch.  Gaz.  St.  Petersb..  1908,  xv,  462. 

3  Santi  Flavio.     Gazette  degli  Ospitali,  1891,  No.  43. 
*  Heath.     American  Lancet,  December,  1888. 


NERVOUS  SYMPTOMS  FOLLOWING  TYI'IIOtl)  FEVER     220 

paralysis,  as  a  parapl('<;'i;i.,  or  ;i„s  ;i,  liciiii|)lc;;i;i,  ;mhI  it  iii;i\'  \n-  <\\u- 
in  the  first  three  instances  to  peripheral  neuritis,  in  the  second 
instance  to  a  myelitis  or  neuritis,  and  in  the  case  of  hemiplegia  to 
C(M'ehral  lesions,  sucii  as  tiiromhosis,  emboh'sm,  hemorrliage,  jirid 
meningo-encephalilis.  Sometimes  llic  nionoplcgia,  or  [jartial  p;ir- 
aplegia,  may  be  due  to  a  poliomyelitis. 

Neuritis. — 13y  far  the  most  common  of  tlicse  ailcclions  is 
the  loss  of  power  due  to  neuritis,  a  conditifjii  which  is  not  com- 
monly met  with  as  a  complication  of  typhoid  fever,  yet  not  so 
rare  as  might  be  supposed.  The  most  exhaustive  and  interesting 
monograph  concerning  this  complication  of  the  disease  is  that 
given  us  by  Ross  and  Bury,^  in  their  essay  on  "Peripheral 
Neuritis,"  first  published  in  the  Medical  Chronicle  and  afterward 
in  a  separate  volume.  So  complete  and  thorough  is  their  study 
of  the  literature  of  the  subject  and  of  the  clinical  aspect  of  the 
condition  that  much  of  the  following  information  is  to  Ije 
credited  to  them. 

Gubler,^  among  several  cases  of  local  palsy  after  typhoid  fever, 
records  the  case  of  a  boy,  aged  sixteen  years,  who  developed,  a  few 
days  after  his  fever  ceased,  a  nasal  voice,  which  was  found  to 
depend  upon  paralysis  of  the  palate.  Shortly  after  this  there  was 
paralysis  of  accommodation.  Tliis  latter  point  is  of  interest  in 
view  of  the  fact  that  Gowers  states  that  this  condition  never  arises 
from  typhoid  fever.  Gubler  also  cites  the  case  of  a  boy  who,  after 
an  attack  of  forty-seven  days,  suffered  from  paresis  in  his  legs  and 
became  unable  to  raise  liimself  in  bed.  His  lower  limbs  were 
feeble,  tremulous,  and  their  muscular  irritability  greatly  increased. 
There  was  also  loss  of  power  in  the  hands,  with  some  spastic  con- 
traction of  the  fingers,  and  the  speech  was  staccato. 

Surmay^  records  two  cases  of  local  paralysis  due  to  this  cause. 
In  one  the  loss  of  power  was  in  the  extensor  muscles  of  the  hand 
and  fingers  and  in  the  extensors  of  the  toes,  and  in  the  other  case, 
weakness  of  the  right  leg  was  followed  by  complete  loss  of  power 

1  Ross  and  Bury.     A  Treatise  on  Peripheral  Neuritis.     Griffin  &  Co  ,  1S93. 

2  Gubler.     Arch.  G^ni^rale  de  Islid.,  1860. 

3  Surmay.     Ibid.,  1865,  i,  678. 


230  COMPLICATIONS  DURIXG  COXVALESCENCE 

in  the  left.  So,  too,  Kraft-Ebing^  speaks  of  weakness  of  the  adduc- 
tors of  the  thigh  and  hyper?esthesia  of  the  skin  suppHed  by  the 
saphenous  nerve.  Bailly-  has  recorded  paraplegia,  anaesthesia, 
and  contractions  in  these  cases,  and  in  two  instances  paralysis  of 
the  palate,  and  NothnageP  records  four  patients  in  whom  the 
ulnar  nerves  were  paralyzed  and  the  ulnar  side  of  the  hand  was 
anaesthetic.  In  all  these  cases  there  was  the  reaction  of  degenera- 
tion, and  they  also  suffered  from  radiating  pains  in  the  upper  and 
lower  extremities.  In  four  other  cases  there  was  partial  paralysis 
of  the  lower  limbs  with  partial  ana\sthesia,  pain,  and  tingling  sen- 
sations, and  in  one  of  these  patients  the  trouble  in  the  lower 
extremities  was  followed  by  weakness  in  the  upper  limbs.  In  still 
another  the  patient  at  the  beginning  of  convalescence  first  had  a 
feeling  of  numbness  and  creeping  in  the  left  leg,  and  after  this, 
paralysis  of  that  limb  gradually  developed.  Later  on  the  exten- 
sors of  the  right  hand  became  paralyzed,  and  four  days  later  some 
of  the  muscles  of  the  left  hand. 

Similar  cases  have  been  reported  by  Leyden'  and  Benedict,  and  in 
one  recorded  by  Eisenlolu*,^  a  man,  aged  thirty  years,  eleven  days 
after  his  temperature  became  normal,  suffered  from  numbness  and 
loss  of  power  in  the  left  leg  and  feet,  ^^dth  violent  pain  in  these 
parts  and  in  both  knees,  followed  the  next  day  by  effusion  into 
the  right  knee  and  a  rise  of  temperature  to  104°.  There  was 
loss  of  power  in  the  left  peroneal  nerve,  and  fourteen  days  later 
the  left  knee  became  swollen.  On  the  sixteenth  day  the  right 
elbow  became  swollen  and  painful  and  the  swelling  of  the  left 
knee  subsided.  The  muscles  supplied  by  the  left  peroneal  nerve 
showed  diminished  reaction,  and  the  left  foot  was  cedematous  and 
in  the  position  of  equino  varus.  On  the  twenty-fourth  day  the 
flexors  of  the  feet  and  the  extensors  of  the  toe  were  completely 
paralyzed,  and  gave  the  reaction  of  degeneration. 

This  case  of  Eisenlohr's  is  of  interest,  first,  because  the  swelling 

1  Kraft-Ebing.     Beobachtungen  unci  Erfahrungen  iiber  Typlius  Abdominalis,  1871. 

2  Bailly.     These  de  Paris,  1872. 

3  Nothnagel.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  ix,  p.  429. 

■•  Leyden.     Klinik  de  Ruckeimiarkskrankheiten,  1875,  Bd.  ii,  Abth.  1,  p.  247. 
'  Eisenlohr.     Arch,  fiir  Psychiatrie  und  Nervenkrankheiten,  1876,  Bd.  vi,  p.  543. 


NERVOUS  SVMPTOAfS   FOLLOW/XG  I'YI'IIOIJ)  FEVKR     2'4] 

passing  from  joiiil,  (o  joiiil  might  have  aroused  a  sus[>icifMi  (h;il  the 
cause  was  septic,  and  because  certain  writers  in  fpiofirig  tlie 
case  consider  it  as  an  instance  of  pjiralysis  corning  on  rJiiring 
relapse.  As  lioss  and  Jiury  |)oiii(  oni,  ii  is  possible  th;it  iIk-  rheu- 
matic poison  was  the  cause  of  bolli  the  joinf  fhanges  an<]  the 
evidences  of  neuritis. 

Additional  cases  of  j)eriph('riii  neuritis  have  also  been  repojferl 
by  Bernhardt/  Vulpian,  and  others.  Thus  a  case  of  deltoid  jKir- 
alysis  has  been  recorded  by  Vulpian/  which  was  in  all  probability 
due  to  a  peripheral  neuritis.  A  young  man,  aged  eighteen  years, 
after  an  attack  of  typhoid  fever,  suffered  from  pain  in  the  arm 
and  developed  loss  of  power  in  the  right  shoulder,  w^ith  atrophy  of 
the  deltoid  muscle.  In  none  of  these  cases,  however,  were  any 
studies  made,  over  and  above  the  clinical  tests  which  are  ordinarily 
employed,  to  prove  positively  that  a  true  neuritis  was  present, 
and  it  was  not  until  Pitres  and  Vaillard^  published  their  paper,  in 
1885,  that  the  first  careful  microscopic  observations  upon  typhoid 
peripheral  neuritis  were  presented.  After  detailing  the  cases  of 
two  patients  who  suffered  from  typhoid  neuritis  they  give  the 
results  of  the  histological  examination  of  nerves  removed  from 
the  bodies  of  four  patients  w4io  died  during  the  active  period  of 
typhoid  infection,  but  in  whom  no  signs  of  peripheral  neuritis  had 
been  noted  during  life.  Cm-iously  enough,  in  tliree  out  of  these 
four  cases  changes  indicating  parenchymatous  neuritis  were  found 
to  be  present,  and  it  is  interesting  to  note  that  one  of  these 
patients  died  as  early  as  the  sixteenth  day  of  the  disease,  wliile 
two  others  died  on  the  thirty-sixth  and  twenty-fourth  days 
respectively. 

Other  instances  of  postmortem  examinations  revealing  periph- 
eral neuritis  in  typhoid  fever  are  those  reported  by  Oppenheim 
and  Siemerling.  In  one  of  these  instances  the  patient  died  in  the 
middle  and  the  other  at  the  end  of  the  second  week  of  the  fever, 

1  Bernhardt.     Deutscli.  Arch,  fur  klin.  Med.,  1S7S,  p.  363. 

•  Vulpian.  D'Accident  Survenus  Pendant  la  Convalescence  de  la  Fife^Te  Tj-phoide, 
Re^-ue  de  :Medecine,  1SS3,  p.  617. 

3  Pitres  and  Vaillard.  Compte  Rendu.  Soc.  de  Biol.,  Paris.  1SS5,  S.  8,  ii,  661,  and  Rev. 
de  M^d.,  Paris,  1SS5,  v.  985. 


232  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

and  in  both  cases,  parenchymatous  degeneration  of  the  periplieral 
nerves  was  found,  in  one  of  -wlncli  it  affected  the  great  saphenous 
and  peripheral  nerves,  and  in  the  other  a  branch  of  the  cutaneous 
nerve  supplying  the  dorsum  of  the  right  foot,  antl  showetl  com- 
plete degeneration  of  many  of  its  fibers. 

Since  these  papers  have  been  published,  others  tleaiing  with 
the  clinical  aspect  of  the  subject  have  been  placed  upon  record  by 
Alexander,'  Handford,"  Archer,^  Humphreys,^  Klumpke-D^jferine,^ 
and  notably  two  cases  reported  by  Bury  in  the  essay  which  has 
been  named.  One  of  these  was  in  a  girl,  aged  eighteen  years,  Avho 
was  seen  eight  months  after  an  attack  of  typhoid  fever  of  varied 
duration  and  severity.  During  the  fever  she  was  suddenly  affected 
by  a  condition  in  which  she  was  unable  to  straighten  out  her  upper 
and  lower  limbs,  and  this  rigidity  persisted  until  she  was  admitted 
to  the  Manchester  Royal  Infirmary,  eight  months  afterward,  when 
it  was  found  there  Avas  great  wasting  of  all  the  muscles  of  the  limbs, 
particularly  in  the  muscles  on  the  front  of  the  thigh  and  outer  part 
of  the  legs.  There  was  drooping  of  the  great  toes  and  the  knee- 
jerks  were  variable,  sometimes  being  excessive  and  sometimes 
being  minus.  The  plantar  reflexes  were  absent,  and  there  was  no 
ankle-clonus.  The  upper  limbs  were  somewhat  flexed,  and  could 
not  he  extended,  and  there  was  atrophy  of  the  thenar  and  hypothe- 
nar  eminences;  there  were  also  marked  disorders  in  cutaneous 
sensibility  in  the  distribution  of  the  radial  nerve.  The  contractions 
could  not  be  overcome  even  when  the  patient  was  put  under  chloro- 
form, and  while  the  paralysis  and  rigidity  remained  for  many 
weeks,  the  patient  ultimately  made  a  complete  recovery. 

In  still  another  case,  long  after  typhoid  fever,  a  man,  aged  forty- 
two  years,  suffered  from  pains  in  his  legs,  in  which  all  the  muscles 
below  the  knees  presented  a  moderate  degree  of  wasting;  he  had 
exaggerated  knee-jerks. 

'  Alexander.     Deutsche  med.  Wochenschrift,  1886,  xii,  529. 

*  Handford  (H.).     Peripheral  Neuritis  in  Enteric  Fever,  Brain,  vol.  xi,  237. 

'  Archer.     British  Medical  .Journal,  1887,  i,  727. 

■•  Humphreys  (F.  R.).  A  Case  of  Peripheral  Neuritis  following  Typlioid  Fever,  Abstr. 
Tr.  Hunterian  Society,  London,  1889-90,  41. 

'>  Klumpke-D^jt'rine.  Des  Polyn(5vrites  en  Gdni^ral  et  des  Paraiysies  et  Atrophies  Satur- 
nines  en  Particulier,  Paris,  1889,  p.  222. 


NKIiVOUH  >S]'MPTOMS  FOLLOWINC  I'VI'IIOII)   /■/■Vhfi     2?>?> 

DerciJin  }i;is  reported  to  us  two  cases  of  |)eiipliff;il  nciniii-,  ;it'l*T 
typhoid  fever,  (J lie  to  the  excessive  admijiistjalion  of  alcohol 
during  the  ilhiess.  Thus  a  \j(\y\  of  fourteen  years  received  on<-  anrl 
a  half  pints  a  (hiy  for  sonic  (inic,  and  (h'\c|()pcd  (yjncal  alctjlioh'c 
neuritis. 

These  cases  give  some  ich.-a  of  tlic  cliaractci-  of  die  \ai'ioiis  forms 
of  peripheral  neuritis  which  follow  typhoid  fever.  Odici-  instance.s 
might  be  quoted  in  which  there  is  doubt  as  to  whether  paraplegic 
symptoms  were  due  to  neuritis  or  to  injury  to  the  tracts  and 
cells  in  the  spinal  cord.  Thus,  Mitchell'  has  recorded  a  ca.se 
of  paraplegia  associated  with  tremor,  in  which  he  thought  that  the 
paralysis  was  due  to  degeneration  of  the  cells  in  the  anterior  cor- 
nua  of  the  spinal  cord,  but  Ross  and  Bury  consider  that  the  rapid 
improvement  of  this  patient  indicated  that  she  was  suffering  rather 
from  a  peripheral  than  a  spinal  disease.  So,  too,  George  Ross' 
has  recorded  a  case  in  which  there  was  paralysis  wath  spastic  con- 
traction of  the  lower  extremities,  v^dth  loss  of  electrical  reaction, 
but  no  diminution  in  the  abilities  of  the  sphincters,  and  in  which 
complete  recovery  took  place. 

That  severe  peripheral  neuritis  may  result  in  tropliic  changes  in 
the  organs  supplied  by  the  nerves  which  are  involved  is  shown  by 
a  case  reported  by  Wedenski,^  of  a  youth,  aged  seventeen  years,  in 
whom,  two  years  after  typhoid  fever,  symmetrical  gangrene  devel- 
oped as  a  result  of  degeneration  of  the  peripheral  nerves.  No 
lesions  w^ere  found  in  the  muscles  nor  in  the  cerebrospinal  nervous 
system. 

Closely  associated  with  true  paraplegia  following  enteric  fevei' 
is  that  partial  paraplegia  or  ataxia  of  the  stage  of  convalescence 
in  which  the  patient  finds  it  difficult  to  use  his  lower  limbs.  Tliis 
lasts  in  nearly  all  severe  cases  for  some  days  after  the  patient  leaves 
his  bed,  and  is  often  persistent  for  some  weeks,  causing  a  peculiar 
waddle  or  stiff-legged  gait,  quite  commonly  met  with  when  the 
illness  has  been  severe  and  the  patient  has  been  inadequately  fed. 

1  Mitchell  (S.  W.).     Boston  Medical  and  Surgical  Journal,  1S79,  c,  245. 

2  Ross  (G).     International  Journal  of  the  Medical  Sciences,  1SS9,  p.  25. 
'  Wedenski.     Wiener  medizinischer  Presse,  189S,  xxxii,  p.  421. 


234  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

In  connection  A\ith  tlie  question  as  to  whether  these  various 
forms  of  paralysis  are  spinal  or  peripheral,  the  followino-  cpiotation 
from  Ross  antl  liury  is  of  importance: 

"While  it  is  probal)le  (hat  a  few  cases  of  muscular  atrophy 
which  follow  typhoid  fever  tlepend  upon  an  anterior  poliomyelitis, 
and  that  a  condition  similar  to  that  of  infantile  paralysis  is  pro- 
iluced,  the  presence  of  sensory  disturbances  in  the  vast  majority 
of  cases  shows  that  the  lesion,  if  in  the  cord  at  all,  is  not  limited 
to  the  anterior  horns,  or  involves  both  the  anterior  and  posterior 
roots,  or  the  mixed  peripheral  nerves.  The  absence  of  spinal 
tenderness,  of  girdle  pains,  and  of  disturbances  of  the  sphincters 
speaks  much  against  an  infection  of  the  spinal  cord  or  its  roots, 
while  the  initial  sensory  distm-bance,  succeeded  by  a  limited 
paralysis  having  a  slow  progressive  march  up  to  a  certain  degree, 
which  varies  according  to  the  severity  of  the  case,  the  paralysis 
then  slowly  receding  and  ultimately,  as  a  rule,  completely  disap- 
pearing, are  points  strongly  in  favor  of  an  affection  of  the  per- 
ipheral nerves." 

An  interesting  case  of  peripheral  neuritis  after  typhoid  fever 
has  been  recorded  by  Putnam,  of  Boston.  In  this  the  patient 
suffered  from  tropliic  changes  in  that  small  abrasions  did  not  heal. 
There  was  marked  analgesia,  and  when  seen  two  years  after  the 
attack  of  the  fever,  tliis  disturbance  of  sensation  extended  to  the 
left  arm  and  shoulder,  the  left  side  of  the  neck  and  trunk  as  far  as 
the  eighth  rib.     Marked  improvement  followed  treatment. 

There  are  tliree  other  classes  of  symptoms  showing  peripheral 
nerve  distm-bances:  First,  cases  in  wliich  excessive  muscular  con- 
tractions are  developed  in  place  of  paralysis,  but  associated  with 
pain  and  hyperaesthesia.  Eleven  of  these  cases  have  been  reported 
by  Ai'an  in  L'Union  Medicale,  July  18,  1855.  The  contractions 
occurred  toward  the  end  of  the  attack  of  typhoid  fever,  and  never 
Avere  met  with  at  the  commencement  of  the  disease.  They  were 
preceded  by  formication,  prickings,  and  numbness  in  the  extremi- 
ties, and  pain  in  the  joints,  and  the  immediate  seizure  was  associated 
with  an  intense  feeling  of  anxiety  and  distress,  the  contractions 
affecting  both  upper  and  lower  limbs,  so  that  many  muscles  exhib- 


NERVOUS  SYMPTOMS  FOLLOW/. \(;  TV I'llOII)   FLVKR     235 

ited  almost  inccssanl,  fihiilhuy  rondnfliotis.  Jiy  gra<Ju;il  in;iiii|>ii- 
lation,  artificial  cxtensioii  ronld  he  ohiairicd,  and  thi.s  ^avo  the 
patient  relief  for  a  short  lime.  In  four  ca.s(,'.s  the  muscles  of  tlie 
trunk  were  affected  and  opisthotonos  was  produced,  the  patient 
being  held  immovable  by  the  muscular  contraction,  which  also 
caused  j^rcat  pain.  These  attacks  lasted  from  a  quarter  of  an  hour 
to  three  hours  and  recurred  from  two  to  ten  times  a  day,  and  after 
the  cessation  of  the  attacks  the  fever  ran  its  ordinary  course  with- 
out any  other  synij)toms  save  an  occasional  numbness  of  the  affecteri 
parts.  Although  three  of  the  patients  died,  Aran  thinks  their 
deaths  were  due  to  the  severity  of  the  fever  and  not  to  the  tetanic 
complication.  These  cases  so  closely  resemble  tetanus  that 
similar  ones  could  be  readily  taken  for  tetanus  if  the  symptoms 
occurred  early  in  the  course  of  typhoid  fever. 

Gubler^  has  recorded  a  case  of  contraction  of  the  hands,  and 
Dewerve  refers  to  this  condition  as  possible  of  occurrence  in  the 
Nouveau  Dictionnaire  de  Medecine  et  de  Chirurgie.  So,  too,  Xoth- 
nageP  refers  to  a  case  of  tonic  contractions  of  the  interosseous 
muscles  lasting  from  one-quarter  to  one-half  an  hour.  Similar 
contractions  ensued  when  the  patient  supported  himself  on  his  toes. 

A  second  class  of  nervous  distiubances  is  closely  associated 
with  the  general  signs  of  peripheral  neuritis,  and  is  thought  by 
some  to  have  become  more  frequent  since  the  general  introduction 
of  the  cold  bath  in  the  treatment  of  typhoid  fever.  These  signs 
have  been  particularly  described  by  Handford,  and  consist  of  great 
hyperaesthesia  of  the  toes  and  heels  of  patients  in  the  latter  part 
of  the  disease  or,  more  particularly,  diu-ing  convalescence. 

Osier,  inwTitingof  this  subject,  states:  "Before  July,  1S90,  when 
the  Brand  method  of  bathing  was  introduced  into  my  wards,  I  had 
never  seen  an  instance.  Since  then  we  have  had  twenty  or  more 
cases,  all  of  which  have  been  bathed.  Not  ha^-ing  met  vrith.  the 
condition  before  using  the  baths,  I  was  inclined  to  regard  it  as  the 
effect  of  the  cold  water;  but  in  a  personal  communication  from 
Dr.  Handford,  I  gather  that  his  cases  were  not  treated  by  the  Brand 

1  Gubler.     Archives  Generale  de  Med.,  xv,  5th  series. 
-  Nothnagel.     Deutsche  Arch,  fur  klin.  Med.,  1872,  9. 


236  COMPLICATIOXS  Dl'RIXG  COXVALESCEXCE 

method,  so  that  it  is  evidently  one  of  these  coincidences  which  are  so 
apt  to  be  misleatling  in  medicine." 

!Myelitis.^A  few  cases  have  been  recorded  in  ^\•hich  a  ra[)itlly 
ascending  paralysis,  usually  terminating  fatally,  has  occurred 
during  the  course  of,  or  immediately  after,  an  attack  of  typhoid 
fever. 

Cases  of  myelitis  or  anterior  poliomyelitis  as  a  result  of  typhoid 
fever  are  so  rare  as  to  be  almost  unknown,  although  Gowers,  as 
already  quoted,  has  stated  that  poliomyelitis  is  more  frequently 
secondary  to  typhoid  fever  than  to  any  other  acute  infectious 
disease. 

Two  cases  of  ascending  myelitis  are  recorded  by 'Raymond  in 
La  Science  de  Mcdecine  for  18<So,  but  in  each  of  these  there  is  good 
reason  to  believe  that  the  lesions  were  really  those  of  nem-itis  and 
not  really  those  of  myelitis,  A  case  has,  however,  been  reported 
by  Shore  in  the  St.  Bartholomew's  Hospital  Reports,  vol.  xxiii,  in 
which  there  was  acute  myelitis  of  the  anterior  cornua  and  involve- 
ment of  three  of  the  eight  cervical  nerves. 

Schiff^  reports  an  undoubted  case  of  acute  hemorrhagic  myelitis 
complicating  a  severe  attack  of  typhoid  fever. 

Cerebral  Lesions. — Hemiplegia  during  the  course  of  typhoid 
fever  is  a  rare  affection.  It  may  be  due  to  hemorrhage,  embolism, 
thrombosis,  or  abscess.  It  is  well  to  remember  that  there  is  a 
particular  tendency  during  typhoid  fever  to  the  formation  of 
thrombi  in  the  arteries,  while  acute  endocarditis  is  so  rare  in  this 
disease  as  to  be  a  curiosity,  from  which  fact  it  would  seem 
reasonable  that  hemiplegia  from  embolism  must  be  very  uncom- 
mon.   (See  case  reported  under  Thrombosis.) 

Gubler,  in  1860,  reported  the  occurrence  of  hemiplegia  during 
typhoid  fever  in  a  young  girl  who  was  also  known  to  be  syphilitic. 
Aphasia  was  present  in  this  case  as  in  other  cases  of  hemiplegia 
noted  in  this  disease  by  later  observers.  Records  of  instances 
of  this  complication  were  very  few  and,  as  a  rule,  incomplete 
until  Sir  Francis  Hawkins  read  an   address   before  the  London 

>  Schiff.     Arcliiv  fur  klin.  Med.,  1899,  xlvii,  175. 


N/'JIiVOUS  SYMTTOMS  FOLLOWING  TYI'IIOID  FIALIi     2'M 

riiiiical  Society  in  LSSO  upon  tliis  sMljjcrl.  Ilawkins  at  tlii.s  tinic 
reported  17  cases  which  he  had  cohected  from  the  Hteratiire  or 
had  personally  observed.  Ilolscher,  in  summarizing  the  2000  fatal 
cases  of  typhoid  fever  at  Munich,  mentions  twenty  cases  as  having 
shown  cerebral  apoplexy,  but  a  study  of  875  fatal  cases  of  typhoid 
fever  in  Ik'rlin,  in  a  series  of  4703  cases  of  this  disease,  did  not  reveal 
one  instance  of  hemiplegia. 

Osier  lias  recorded  a  case  of  a  yoinig  physician  who  was  taken  ill 
with  typhoid  fever,  on  the  fourteenth  day  had  a  temperature  of  104°, 
which,  however,  fell  the  following  morning  to  100.7°,  and  in  the 
next  three  or  four  days  the  temperature  had  not  reached  102.5° 
when  the  rash  developed  and  the  spleen  became  palpable.  Twenty- 
four  hours  later,  when  all  the  symptoms  of  the  case  seemed  favor- 
able, he  was  suddenly  seized  witli  uneasy  feelings  in  his  head,  the 
pupils  were  dilated,  and  in  a  few  minutes  he  suffered  from  a  short, 
sharp  general  clonic  convulsion,  beginning  almost  simultaneously 
in  both  arms;  the  eyes  showed  marked  conjugate  deviation  to  the 
left  and  upward,  and  tlie  head  was  also  turned  to  the  left.  The 
convulsions  were  severe  at  short  intervals  for  an  hour,  then 
became  less  intense,  and  finally  ceased  altogether  for  several  hours; 
they  were  accompanied  by  profound  unconsciousness,  and  die 
severer  ones  occasioned  great  embarrassment  to  the  respiration. 
In  the  interval  the  patient  was  conscious,  spoke  to  those  about  him, 
and  seemed  to  understand  questions.  Later  in  the  evening  the  con- 
vulsions recurred  with  great  severity,  and  after  five  hours  the 
patient  died  in  a  severe  one.  These  convulsions  were  general,  but 
were  most  marked  on  the  right  side  of  the  body.  A  postmortem 
examination  held  by  Flexner  revealed  thrombosis  in  the  ascending 
parietal  and  parietotemporal  branches  of  the  middle  cerebral 
artery.  The  meninges  over  these  vessels  contained  small  hemor- 
rhages, and  the  brain-matter,  while  not  softened,  showed  small 
extravasations  of  blood.  Small  but  quite  extensive  punctiform 
hemorrhages  could  be  seen  to  occupy  the  cortex  and  adjacent 
white  substance  in  the  immediate  neighborhood  of  the  tlu'ombosed 
vessels. 

Out  of  the  well-known  120  cases  collected  bv  William  Osier  of 


23S  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

hemiplegia  in  children,  there  was  no  instance  of  hemiplegia  fol- 
lowing typhoid  fever,  and  in  IGO  cases  collected  bv  Wallenberg, 
four  only  occurred  after  typhoid  fever.  Osler,^  however,  reports 
two  cases  of  post-typhoid  hemiplegia.  One  of  these  occurred  in 
a  jrirl,  ajjed  six  vears.  Almost  two  months  after  the  beo-inning  of 
her  illness  she  was  seizeil  with  violent  convulsions,  which  were 
confined  to  the  head,  right  arm,  and  leg;  she  became  unconscious. 
Later  it  was  noticed  that  the  right  side  was  completely  paralyzed, 
including  the  face,  and  that  there  was  total  loss  of  speech  and 
aphasia,  lasting  for  seven  weeks.  Gradually  the  patient  largely 
recovered  from  this  paralysis,  but  complete  recoAery  did  not  ensue. 
The  second  case  was  that  of  a  clergyman,  aged  twenty-five  years, 
who  \^as  seized  ^\itli  convulsions  fourteen  days  after  going  to  bed 
with  headache,  fever,  and  diarrhoea.  In  this  case  also  partial 
recovery  took  place,  but  Osier  did  not,  at  the  time  of  making  his 
report,  consider  that  complete  recovery  would  be  possible.  The 
paralyzed  arm,  the  left,  many  months  after  the  attack,  was  affected 
by  wide  irregular  choreiform  movements  on  attempting  any  volun- 
tary effort,  but  the  mental  condition  was  excellent. 

Another  case  of  this  character  was  reported  to  the  Johns  Hop- 
kins Medical  Society  by  Blumer:^  that  of  a  little  girl,  who,  one 
week  after  convalescence  had  begun,  and  who  had  been  eating 
solid  food,  was  seized  ■v\'ith  violent  convulsions,  which  were  con- 
fined almost  entirely  to  the  right  side.  These  convulsions  lasted 
for  eight  hours,  and  were  followed  by  paralysis  of  the  right  side; 
five  weeks  after  the  onset  of  these  convulsions  she  began  to  recover 
both  the  power  to  move  the  arm  and  leg,  and  also  that  of  speech. 
She  also  sufferetl  from  amnesic  aphasia;  ultimately  almost  complete 
recovery  took  place,  so  that  there  was  only  slight  dragging  of  the 
foot,  and  some  pure  motor  aphasia.  The  arm,  however,  did  not 
materially  improve,  and  was  affected  by  rigid  paralysis,  though  no 
sign  of  facial  paralysis  was  present,  and  the  tongue  was  protruded 
straight.     Blumer  believed  that  the  case  was  due  to  thrombosis. 

In  the  same  journal  Thayer  records  two  other  cases  of  this 

1  Osier.     Journal  of  Nervous  and  Mental  Disease,  May,  1896. 
-  Blumer.     Johns  Hopkins  Hospital  Bulletin,  April,  1896,  p.  72. 


NERVOUS  SYMPTOMt^  FOLLOWING  TYrilOII)  l<'l-:VER     2'-;9 

cliar{u;i('r  seoMi  in  tlio  Mussucbii setts  rj(;rH'ral  Jl(jspil;il.  On  (Ik- 
tenth  (lay  of  the  illness  in  one  case  the  ward  onJerly  IVmjikJ  at  I  a.m. 
that  the  patient  was  unable  to  move  the  right  arm  and  leg;  the  face 
was  flushed,  the  eyes  half  closed,  the  ))iij)ils  ((iikiI,  ;ind  eyehalls 
rolled  npward.  The  patient's  mental  condition  wjis  very  stii[)ifl. 
Eight  days  later  the  patient  was  distincdy  hcttcr,  un;d)lc  to  speak, 
but  evidently  understood  what  was  siiid  lo  liim;  Ik-  fould  noi  pio- 
trude  his  tongue,  but  later  was  able  (o  read  die  jjnpcr  ;ind  U)  say 
a  few  words. 

The  other  case  was  that  of  a  girl,  aged  ten  years,  admitted  to  the 
Massachusetts  General  Hospital  on  the  fifth  day  of  typhoid  fever, 
who  was  found  on  the  twenty-third  day  of  her  disease  to  lie  prin- 
cipally upon  the  right  side,  and  failed  to  answer  questions.  The 
next  day  the  patient  could  not  speak,  although  she  apparently 
understood  what  was  said  to  her;  the  tongue  was  protruded 
straight;  the  face  was  not  paralyzed. 

In  other  words,  these  are  two  cases  illustrating  the  onset  of 
complete  right-sided  hemiplegia  with  motor  aphasia. 

A  case  of  hemiplegia  has  also  been  recorded  by  Newbolt,^  in 
which  a  locomotive  fu'eman,  aged  twenty-one  years,  suffered  from 
loss  of  power  in  the  left  arm  and  leg  during  the  course  of  a  relapse. 
There  was  aphasia,  and  the  tongue  w^as  protruded  to  the  right; 
there  was  drooping  of  the  right  eyelid,  and  some  dysphagia.  Per- 
fect recovery  did  not  occur.  The  case  was  thought  to  have  been 
due  to  thrombosis. 

Still  another  case  of  hemiplegia  complicating  typhoid  fever  is 
recorded  by  Imradi.^  The  case  had  been  considered  one  of  influ- 
enza, and  the  patient  was  allowed  to  go  out  on  the  fifteenth  day, 
when  he  suddenly  lost  consciousness  and  remained  unconscious 
for  hours;  when  seen  he  was  suffering  from  left-sided  hemi- 
plegia. The  fever  ran  a  typical  characteristic  course,  and  recovery 
occurred. 

Imradi  asserts  that  there  were  only  fifteen  similar  cases  to  be 
found  in  literature  at  that  time. 

1  Newbolt.     London  Lancet,  August  27,  1S93. 

2  Imradi.     Centralblatt  fiir  med.  Wissenschaften,  October  25,  1891. 


240  COMPLICATIOXS  DURIXG  COXVALESCEXCE 

A'iilj)ian'  has  recorded  a  case  of  obstruction  of  the  left  Sylvian 
arterv  in  the  coiu'se  of  typhoid  fever,  causing  riglit  hemiplegia  and 
aphasia  in  a  male  of  seventy  years. 

Under  the  title  of  "A  Case  of  Hemiplegia  of  Gradual  Onset 
following  a  Severe  Attack  of  Enteric  Fever  and  Terminating  in 
Insanity"  (which  was  probably  hysteria),  Stevens"  has  recorded 
the  histor}-  of  a  man,  aged  twenty-two  years,  who  three  months 
after  recovery  from  this  tlisease  found  he  had  difficulty  in  approxi- 
mating the  fingers  of  his  left  hand  to  one  another.  Stevens  tells  us 
that  "  the  .fingers  are  flexed  upon  the  palm  of  the  hand  more  or  less. 
They  can  passively  and  slighdy,  by  voluntary  effort,  be  extended 
within  narrow  limits  (see  figure  in  Glasgow  Medical  Journal). 
Tlie  thimib  is  turned  outward  and  flexed  at  the  interphalangeal 
joint.  Forcible  extension  of  the  fingers  is  accompanied  by  consid- 
erable pain,  but  the  thumb  is  less  painful  in  this  respect.  The 
wrist-joint  is  fixed,  evidently  largely  by  muscular  spasm,  and  not 
bv  definite  ankvlosis.  jNIovement  of  flexing:  the  forearm  on  the 
arm  is  perfectly  easily  accomplished,  but  it  is  accompanied  by 
considerable  fine  tremor  of  the  whole  arm.  On  attempting  to 
raise  the  left  arm  above  the  head  it  becomes  evident  that  there  is 
little  movement  at  the  shoulder-joint.  Most  of  the  movement 
is  accomplished  by  moving  the  arm  and  shoulder  en  masse,  and,  as 
a  result,  the  range  is  much  more  limited  than  on  the  other  side. 
There  is  no  definite  wasting  of  any  of  the  arm  muscles.  The  posi- 
tion of  the  thumb  in  relation  to  the  other  fingers  is  fiu-ther  noted. 
It  is  turned  around  in  such  a  way  that  it  rests  upon  the  radial 
aspect  of  the  first  phalanx  of  the  forefinger.  As  regards  the  foot, 
there  is  noted  a  spastic  condition  evidently  involving  the  extensors, 
so  that  the  toes  are  all  drawn  well  up  upon  the  dorsum  of  the  foot, 
the  first  phalanx  in  each  case  being  drawn  far  back  upon  the  meta- 
tarsal bone.  The  extensor  tendons  stand  out  like  cords.  Despite 
this,  movement  of  the  ankle-joint  is  fairly  free,  although  rather 
jerky.  The  power  of  the  muscles  of  the  thigh,  as  tested  by  making 
and  resisting  movements  of  flexion  and  extension  of  the  knee,  is 

1  Vulpian.     Re\-ue  de  Mddecine,  1884,  p.  162. 

-  Stevens.     Glasgow  Medical  Journal,  January  to  July,  1897,  vol.  xlvii. 


N/<J/iVO(/S  HYMI'TOMH  FOLLOWING  TYI'IIOIb   FEVKU     211 

fairly  ^()()(1  in  ))()lJi  lower  (^xfrcmitlcs,  and  no  a)>|)C('ci;il)lc  ^WWi-Yvwcv. 
is  mudc  out  between  tlie  two  sides. 

"Sensation  is  tested  in  both  upper  and  lower  exircnn'tie-,,  and 
found  to  b(!  normal.  The  reflexes  (tendo;ij  in  I  he  Kit  w^tyvv 
cxtrenn'ty  are  abolislied;  in  the  ri^ht,  normal.  The  suj^erfieial 
abdominal  and  eremasteric  reflexes  on  th(;  ri/^lif  sidr-  are  easily 
elicited;  the  former  can  be  I'ainlly  brou;^d)l  out  on  llie  let!  side, 
but  the  latter  on  the  left  side  cannot  be  elicitfid.  'J"he  knee  reflex 
is  distinctly  exaggerated  on  the  left  side,  and  the  ankle-clonus  is 
very  marked,  while  on  the  right  side  the  knee  reflex  is  normal,  and 
there  is  no  ankle-clonus." 

Later,  the  patient  became  insane  and  passed  into  an  asylum, 
and  the  asylum  physicians  made  the  following  report  on  his  case, 
deciding  that  the  condition  was  male  hysteria. 

"The  points  that  guided  us  in  inclining  to  a  diagnosis  of  the 
hysterical  nature  of  the  case  were  as  follows : 

"1.  The  varying  intensity  of  the  symptoms.  The  flexion  of 
the  arm  was  not  constant;  at  times  it  admitted  of  a  limited  move- 
ment and  a  limited  power  of  passive  extension,  but  at  other  times 
the  spasm  of  the  flexors  was  intense,  and  manipulation  was  almost 
consciously  resisted.  The  symptoms  in  the  leg  varied  even  more 
than  in  the  arm. 

"2.  The  comparative  absence  of  atrophy  of  muscles,  considering 
the  duration  of  liis  illness  (since  the  middle  of  1895).  Measure- 
ments taken  last  month  showed  that  while  there  was  a  degree  of 
atrophy,  the  greatest  difference  was  between  the  right  and  left 
thighs,  which  was  only  one  and  one-quarter  inch. 

"3.  Apparently  normal  response  of  the  muscles  to  farad ic  irri- 
tability, 

"4.  The  complete  disappearance  of  the  symptoms  under  deep 
chloroform  necrosis. 

"There  were  also  the  peculiar  hysterical  postm'e  of  the  patient 
and  the  difference  between  the  symptoms  in  the  two  limbs.'' 

Still  another  case  of  hemiplegia  is  reported  in  the  Johns  Hop- 
kins Hospital  Bulletin  for  July,  1896,  by  Haynes,  as  having  pre- 
sented itself  at  the  Brooklyn  Eye  and  Ear  Hospital.  A  man,  aged 
16 


242  COMPLICATIOXS  DUIUXG  COXVALESCENCE 

thirty  years,  suffered  in  October,  1S95,  from  an  attack  of  typlioid 
fever  lasting  twenty-one  days.  On  the  fourteenth  day  his  left  arm 
became  paralyzed,  and  when  able  to  sit  up  it  was  found  that  both 
upper  and  lower  cxtrcniitics  iVh  numb,  altliouuii  i\]vvv  w;is  no  loss 
of  sensation.  Tliis  condition  persisted  for  a  couple  of  months, 
when  impro^•ement  began,  first  in  the  leg;  almost  completely  re- 
covery ensued,  so  that  only  slight  loss  of  motion  and  inability  existed. 
There  was  no  evidence  of  facial  paralysis  or  convulsions  in  this  case. 

As  an  indication  of  the  possible  effects  of  embolism  of  the  cra- 
nial vessels,  the  case  recorded  by  ]\Iensel  may  be  cited,  in  which 
necrosis  of  the  skull  followed  the  formation  of  a  clot  in  the  middle 
meningeal  artery. 

By  far  the  most  extensive  research  into  the  literature  of  typhoid 
hemiplegia  has  been  made  by  Smithies,^  who  has  collected  42 
cases  and  added  one  case  which  was  under  his  own  care. 

From  Smithies'  valuable  paper  we  quote  freely: 

Sex. — Of  the  33  cases  in  which  the  sex  is  mentioned,  23  are 
males,  9  are  females;  in  2  instances  the  sex  was  not  recorded. 

Age. — Four  cases  were  five  years  or  younger,  5  were  between 
five  and  ten  years,  8  cases  between  ten  and  twenty,  13  cases 
between  twenty  and  thirty,  and  2  cases  were  more  than  thirty 
years  of  age.  As  is  readily  seen,  the  age  at  which  the  majority  of 
the  cases  of  this  complication  develop  is  during  yoinig  adult  life, 
which  period  is  also  the  one  when  the  patient  is  most  likely  to 
contract  the  initial  disease. 

Aphasia. — In  32  cases  in  which  disturbances  in  speech  were 
recorded,  aphasia  occurred  in  26.  It  was  absent  in  four  cases,  and 
in  the  remainder  of  the  cases  there  was  unconsciousness,  with  later 
faltering  speech  or  death  before  the  presence  or  absence  of  aphasia 
could  be  determined. 

Time  of  Onset. — The  time  of  onset  varied  widely.  Of  the  30 
cases  in  which  a  detailed  report  is  given,  in  but  one  did  the 
hemiplegia  occur  in  the  first  week.  Eight  instances  are  reported 
in  which  the  condition  appeared  during  the  second  week,  eight 
during  the  third  week,  two  during  the  fourth,  and  the  remainder 
during  convalescence.     In  one  case,  in  winch  convalescence  from 

'  Smithies.     Journal  of  the  American  Medical  Association,  August  3,  1907. 


NERVOUS  SYMPTOMS   h'OlJ.OWlNC   TYI'IIOIh   !■' i:V I'lli,     2^'.', 

tlic  iiiiliiil  jilliU'k  wjis  niiicli  prolonn-f'd^  (hi  ;  coniiili'nlion  ocfiirici 
in  the  cinlilli  iiiotiUi. 

Mode  of  Oii.srL — In  10  cjiscs  the  lictniplc^ia  was  preceded  by 
convulsions,  in  foiii-  instances  tlicse  cunu!  on  sudflcniy  and 
violently.  With  the  convulsions  there  was  usually  associated  uncon- 
sciousness, either  temporary  or  lontr  continued.  In  four  instances 
there  was  delirium.  In  three  there  was  stupor.  In  s(;vcral 
instances  a  very  severe  headache  preceded  tlie  onset  of  the  paraly.si.s. 
In  a  few  instances  there  was  very  hio;h  tenijxratnrc,  with  low 
muttering  delirium  and  nervous  symptoms. 

The  Side  Affected. — In  21  cases  the  paralysis  was  on  the  right 
side,  in  10  cases  on  the  left.  In  the  remaining  cases  no  note  was 
made  of  the  side  affected.  In  only  two  cases  of  right-sirled  paralysis 
was  aphasia  absent.  In  three  of  the  left-sided  paralyses  aphasia 
was  present. 

Autopsy  Findings. — Five  of  the  brains  revealed  the  presence  of 
a  clot  in  the  middle  cerebral  artery  or  its  branches,  while  in  the 
remaining  fatal  cases  the  findings  were  not  recorded. 

Results. — In  6  of  the  cases  the  patients  died.  Twelve  recovered 
completely.  The  shortest  time  to  complete  recovery  was  twelve 
weeks.  In  the  great  majority  of  the  remaining  cases  there  was  a 
gradual  improvement  of  the  paralysis.  This  was  particularly  true 
of  the  gross  movements,  while  the  finer  movements  requiring  deli- 
cate coordination  were  late  in  returning  or  entirely  lost.  In  three 
instances  the  hemiplegia  persisted  without  any  improvement. 
Recovery  from  the  paralysis  w^as  usually  noted  as  being  more  rapid 
and  more  complete  in  the  lower  limbs,  mth  the  muscles  of  the  feet 
and  lees  regaining;  their  functions  earlier  than  those  of  the  arm 
and  hands.  Muscular  weakness,  more  marked  than  that  usually 
noted  in  post-typhoid  states,  was  frequently  commented  upon. 
In  many  cases  there  was  moderate  atrophy  of  the  parts  involved. 
Contractures  both  early  and  late  were  commonly  present.  In  the 
patients  in  whom  hemiplegia  was  associated  with  aphasia  the 
recovery  from  the  latter  disturbance  was  much  slower  and  less 
complete  than  from  the  former  lesion.  In  some  cases  there  was  but 
slight  improvement  in  the  aphasia.  In  but  a  few  of  the  patients 
was  there  complete  recovery.     In  no  instance  was  the  speech  as 


244  COM  FLIC  ATIOXS  DURIXG  CONVALESCENCE 

perfect  as  before  the  illness.  In  the  non-fatal  cases  the  loss  of 
bladder  control  ■nas  but  temporary.  Athetoid  movements  on 
voluntary  eft'ort  were  noted  by  Osier  and  ]Jarre(t. 

The  mentality  seems  to  suffer  no  serious  alteration.  In  a  few 
patients,  even  without  complicating  aphasia,  slow  cerebration  has 
persisted  for  some  time  after  the  febrile  state.  Confusion  and 
hesitancy  of  speech  is  fairly  common,  sometimes  lasting  for  months. 
There  seems  to  be,  in  some  instances,  more  than  ordinary  tendency 
towai'd  post-typhoid al  neuroses,  particularly  of  the  psychic  nature. 

Prognosis. — Death  occiUTcd  in  about  15  per  cent,  of  the  cases 
in  Avliich  hemiplegia  developed.  In  these  cases  the  lesions  in 
the  bowel  did  not  appear  to  have  been  the  most  serious  factor  in 
causing  the  fatal  termination.  In  the  non-fatal  cases  the  prognosis 
is  for  gradual  partial  recovery.  In  about  8  per  cent,  of  the  cases 
there  was  no  improvement. 

Aphasia  or  other  disturbances  of  speech  after  enteric  fever  have 
also  been  recorded  by  a  number  of  observers  without  simultaneous 
hemiplegia.  Thus,  HutineP  tells  us  that  aphasia  always  occurs  in 
children,  and  more  frequently  in  boys  than  in  girls.  In  some  of 
these  instances  the  condition  arises  from  embolism,  but  in  other 
cases  recovery  has  ensued  so  rapidly  that  no  severe  organic  cause 
of  this  character  could  have  been  present,  and  this  has  been  proved 
by  the  failure  to  find  embolism  at  autopsy.  Leyden  has  expressed 
the  view  that  such  cases  may  be  due  to  a  mild  degree  of  encepha- 
litis with  rapidly  absorbed  exudation. 

Mental  disturbance  following  typhoid  fever  is  by  no  means 
rare,  and  varies  in  degree  from  slight  mental  enfeeblement  and 
inability  to  do  mental  work  to  marked  insanity.  When  the  patients 
are  violent  they  are  said  by  some  persons  to  have  "asthenic  mania." 
It  is  not  mania,  but  the  insanity  of  profound  mental  and  physical 
depression.  These  variations  from  the  normal  are  usually  fol- 
lowed by  recovery,  as  is  pointed  out  in  the  interesting  chapter 
on  the  mental  disorders  of  the  late  stage  of  typhoid  fever,  wliich 
has  been  contributed  to  this  essay  by  the  senior  author's  friend  and 
colleague,  Dr.  F.  X.  Dercum,  Professor  of  Mental  and  Nervous 
Diseases  in  the  Jefferson  Medical  College. 

>  Hutinel.     Etude  f-ur  la  Convalescence  et  les  Kechute  de  la  Fievre  Tyishoide,  Paris,  1883. 


NERVOUS  SYMPTOMS   FOIJA)\VIN(l   'rVI'IIOID   FEVKU     2'ir> 

Tremors. ^ — Rathcry'  .md  Ilnlincl  have  recorded  e;i  ,e  ,  of  pfj.st- 
typhoid  (i-einor.  In  one  ol"  l{;Uh(!ry'.s  cases  it  persisted  fit'ieen 
moiitlis  id'ter  the  fever  ee;ised.  Siinihir  eases  have  heeii  reer,i(|<(| 
by  I^'reiiiid.'' 

Fry,''  of  St.  liOiiis,  reeords  a  case  of  so-eahed  paralysis  agitans 
following  immediately  after  typhoid  fever.  The  I  rouble  began  with 
the  ending  of  the  fever  in  a  tremor,  which  gradually  increase*!  in 
violence,  and  chiefly  involved  the  right  arm  and  later  the  left. 
Still  later  the  legs  were  involved.  No  definite  reasf)n  foi'  Ix  liev- 
ing  the  case  to  be  Parkinson's  disease  and  not  f>ne  of  onh'nary 
tremor  is  vouchsafed. 

Amaurosis  and  Strabismus. — Gubler*  has  recorded  amaurc^sis 
and  strabismus  after  typhoid  fever,  and  the  latter  symptom  has 
also  been  seen  by  Nothnagel.'' 

Paralysis  of  the  soft  palate  has  also  been  recorded  by 
Gubler,  and  of  the  vocal  cords  by  Tiirck  and  Nothnagel.  All 
these  symptoms  are  but  evidences  of  the  types  of  peripheral  neuritis, 
already  discussed. 

Laryngeal  Paralysis. — Bouley  and  Mendel"  state  that  para- 
lysis of  the  vocal  cords  following  typhoid  fever  is,  in  their  opinion, 
an  exceedingly  rare  condition.  They  claim  they  have  only  found 
ten  other  cases  in  literature  which  are  carefully  described  and 
three  others  briefly  mentioned.  In  some  of  these  cases  there 
was  complete  paralysis  of  the  recurrent  laryngeal  nerve  with 
profound  paralysis  of  the  adductors.  Bernoud^  has  also  reported 
cases. 

Paralysis  of  the  laryngeal  muscles  is  probably  more  common 
than  is  generally  thought,  arising,  as  a  rule,  from  neuritis.  Thus, 
Przedlorski  found  in  100  consecutive  cases  no  less  than  25  cases 
with  paralysis. 

Some  years  since,  at  a  meeting  of  the  Laryngological  Section  of 
the  College  of  Physicians  of  Philadelpliia,  Dr.  MacCoy  reported 

'  Rathery.     Des  Accidents  de  la  Convalescence,  Paris,  1875. 

''■  Freund.     Inaugural  Dissertation,  Breslau,  18S5. 

^  Fry.     Journal  of  Nervous  and  Mental  Disease,  1S97,  p.  465. 

<  Gubler.     Loc.  cit.  s  Nothnagel.     Loc.  cit. 

s  Bouley  and  Mendel.     Archives  G^n^rales  de  M^deeine,  December,  189-1. 

'  Bernoud.     Lyon  M^dicale,  March  28,  1897,  p   453. 


246  COMPLICATIOXS  DURING  CONVALESCENCE 

three  cases  of  larvno;eal  paralysis  c()in})licatinii'  typhoid  fever.  In 
(Joino;  so  he  well  said  in  his  preliminary  remarks: 

"We  can  most  simply  classify  these  paralyses  under  the  various 
functions  performetl  by  the  larynx.  Keeping  clearly  in  mind  that 
the  chief  fimction  of  sets  of  laryngeal  muscles  is  to  open  and  close 
the  glottis,  we  can  simplify  the  clinical  facts  by  grouping  them 
under  the  two  heads  of  paralysis  of  adduction  and  of  abduction. 
Paralysis  of  adduction  in  its  various  forms  is  of  very  great  interest, 
and  enters  largely  into  our  most  interesting  laryngological  experi- 
ences; but  it  concerns  phonation  only — a  most  wonderful  function, 
but  not  necessary  to  life.  Abduction,  on  the  other  hand,  concerns 
the  very  existence  of  Hfe — respiration.  A  moment's  faltering  in 
the  function  of  the  openers  of  the  larynx,  and  we  cease  to  exist. 
Being  then  of  so  vital  importance,  we  must  promptly  recognize, 
during  the  course  of  a  prolonged  and  wasting  acute  disease,  like 
typhoid  fever,  the  imminent  risk  to  life  when  the  abductor  muscles 
are  paralyzed." 

Dr.  ISIacCoy  has  been  good  enough  to  send  us  the  following 
reports  of  his  cases  for  mention  in  these  pages : 

The  first  case  he  saw  was  one  of  posterior  crico-arytenoid  para- 
lysis. It  was  double  or  bilateral,  and  occm-red  in  a  case  of  typhoid 
fever  at  a  suburban  hospital.  The  subject  was  a  young  man  who 
had  had  a  severe,  prolonged,  and  complicated  attack.  The  patient 
had  been  ill  for  over  two  months,  was  greatly  emaciated,  and  pro- 
foundly debilitated.  One  night  he  was  suddenly  seized  \Wth  a  suf- 
focative attack  simulating  croup,  (jetting  no  relief  whatever  from 
remedies  applied.  Dr.  MacCoy  was  asked  to  see  the  case.  The 
patient  was  greatly  distressed  in  his  respiration  and  cyanosed. 
Inspiration  was  performed  laboriously,  each  inspiration  being 
accompanied  by  stridor,  and  the  patient  appeared  almost  mori- 
bund. Laryngoscopic  examination  showed  a  complete  double 
paralysis  of  the  openers,  the  vocal  bands  remaining  fixed  in  the 
median  line.  Accompanying  paralysis  of  the  arytenoid  muscles 
with  loss  of  tension  enabled  the  patient  to  get  a  little  air  through  a 
small  triangular  slit  at  the  most  posterior  portion  of  the  glottis. 
As  promptly  as  possible  an  adult  intubation  tube  was  inserted  into 
the  larynx.     This  was  accomplished   without  much  distress  or 


NERVOUS  SYMPTOMS   FOfJ/)WIN(!  'lYI'llOII)   FEVKU     217 

trepidation  on  the  pari  of  iIk'  piilicnt.  'I'Ih-  cfrcfi  of  ihc  iiiiul.;itioij 
was  magical;  coinj)l(>te  relief  to  Wrejitliitig  install tly  followed,  ;ind 
in  a  few  minutes  tli(^  patient  was  in  a  quiet  sle(;p. 

The  second  subject  presented  himself  fcjr  consultatifHi.  I  le  was  a 
young  man,  aged  twenty-three  years.  lie  wore  a  frnclieofoniy  tuhf. 
The  history  showed  that  he  had  liad  a  severe  attack  of  typhoid 
fever  in  the  South  a  few  months  previously.  During  convales- 
cence he  was  seized  with  a  grave  suffocative  attack,  and  was  in 
such  a  serious  condition  as  to  require  tracheotomy,  which  relieved 
him  completely.  Examination  of  the  larynx  showed  a  complete 
fixation  of  the  vocal  hands  in  the  mecJian  line.  This  patient  could 
not  do  without  the  tube,  and  he  required  it  when  last  under  obser- 
vation. He  has  a  most  clever  device  of  a  valve  and  rubber  tubing 
and  rubber  bulb  connected  with  the  cannula,  by  which  air  is  made 
to  close  the  valve  against  the  mouth  of  the  cannula,  and  so  he  is 
enabled  to  carry  on  conversation  with  ease  and  fluency.  In  this 
case  intubation  was  attempted  but  failed  of  introduction.  The 
subject  enjoys  good  health  and  is  active  in  business  pursuits. 

The  third  case  was  a  soldier  in  one  of  the  city  hospitals,  who 
was  suffering  from  great  dyspnoea.  Laryngoscopic  examination 
showed  complete  apposition  of  the  vocal  bands  in  the  median  line, 
with  enough  relaxation  of  tension  and  arytenoidal  paralysis  to 
allow  a  little  air  to  enter.  Intubation  was  strongly  urged,  but  the 
visiting  physician  was  reluctant,  and  the  subject  died  of  exhaustion 
in  a  short  time.  In  MacCoy's  judgment,  prompt  intubation  in 
this  case  would  have  saved  the  man's  life. 

Chorea. — Cases  of  chorea  have  been  recorded  by  Rilliet  and 
Barthez,  but  these  may  have  been  cases  of  tremor  rather  than 
chorea. 

Myositis. — Sometimes  in  the  convalescence  a  curious  state  is 
developed  in  which  the  muscles  of  the  lower  extremities  become 
painful,  somewhat  brawny,  and  even  slight  redness  may  appear  in 
the  skin  covering  them.  Usually  this  is  unilateral,  but  it  may  be 
bilateral.  INIost  commonly  it  affects  the  calf  of  the  leg,  and  pain  is 
developed  on  pressure  or  on  movement,  active  or  passive.  Osier 
believes  tliis  to  be  a  myositis.  Whatever  it  may  be,  the  senior 
author  can  indorse  the  statement  that  the  condition  is  painful, 


248  COMPLICATIOXS  DURING  COXVALKSCENCE 

from  liis  own  experience,  although  the  condition  was  not,  in  his 
case,  well  developetl. 

Typhoid  Spine. — In  1889  ^^  P.  Gibney,  of  New  York,  de- 
scribed,  under  the  name  of  "typhoid  spine,"  a  condition  in  which 
there  develops,  often  some  days  after  the  ])atient  is  uj)  and  about, 
and  often  only  after  some  very  slio;ht  jar  or  trauma,  great  tender- 
ness of  the  spine,  and  pain  in  the  back  and  in  the  legs  when  they 
are  moved.  When  Gibney  introduced  the  term  "typhoid  spine" 
he  distinctly  stated  that  the  term  carried  Avith  it  no  pathological 
commitment,  but  his  suggestion  was,  that  a  periosteal  lesion,  in- 
flammatory in  character  and  caused  by  the  presence  of  the  typhoid 
bacillus,  would  explain  the  condition.  Soon  after  the  original 
paper  was  published  other  reporters  publislied  notes  upon  cases 
having  fixed  deformity,  and  the  term  ''spondylitis"  was  employed 
to  designate  a  destructive  lesion  in  the  bodies  of  the  vertebrae  re- 
sulting in  deformity  such  as  is  found  in  Pott's  disease  of  the 
spine. 

There  has  been  much  dispute  as  to  the  nature  of  the  changes 
in  these  cases.  Gibney's  view  of  the  organic  change  in  the  perios- 
teum was  not  received  with  favor  by  all,  and  some  few  men,  notably 
Osier,  inclined  to  the  belief  that  in  most  cases  the  condition  was  a 
neurosis.  Of  late  years  there  has  been  a  strong  tendency  to  return 
to  the  original  view  of  organic  change  in  and  about  the  vertebrse. 
As  tliis  condition  is  one  in  which  we  have  no  fatalities,  although 
the  subjective  symptoms  seem  out  of  all  proportion  to  the  objec- 
tive symptoms,  it  w^as  not  until  the  common  and  more  skilful  use 
of  the  x-raj  was  resorted  to,  that  an  attempt  to  determine  the 
changes  that  take  place  in  the  spine  was  made. 

Fluss^  collected  42  cases  in  1905,  while  Silver"  has  since,  by  a 
careful  search  of  the  literature,  l^een  able  to  find  67  cases  reported. 
In  his  analysis  he  reduces  this  niuiiber  to  53,  because  several  of  the 
cases  were  not  fully  reported. 

We  quote  freely  from  Silver's  extensive  report:  The  time  of 
onset  of  the  first  symptoms  of  the  spinal  affection  occurred  as 
follows : 

'  Fluss.     Centralblatt.  f.  d.  Grenzgeb.  d.  Med.  u.  Chin,  No.  8,  Bd,  xvii  to  xxi. 
2  Silver.     Amer.  Jour.  Orthopedic  Surgery,  October,  1907. 


NERVOUS  SYMPTOMS   FOfJ/JW/XO   TYI'IIOII)   FEVICH     2V.i 


()nH(;t  (Iiiriii«  fovcr 


()nH(!t  during  nouviiU-.Hrjtiir.f 

OriHct  williiii  oik;  rruuilli  after  convuloHcence 
Onact  within  two  irionlliH  after  (;onvaleHccri<:<; 
Onwet  witl)iri  tliree  montliH  after  convalescence 
Onset  within  four  rnontli.s  after  convaleHcence 


4 
.'iO 
14 
3 
1 
1 


Thus  in  00  per  cent,  the  onset  occurred  before  tlie  end  of  the 
first  month  foUowin^  convulescence.  Some  rise  in  temperature 
occurred  in  28  cases,  or  in  53  per  cent,  rracticully  all  f>f  the  .severe 
cases  had  a  rise  of  tem{)erature  at  some  time. 

Pain  in  the  back  is  a  constant  symptom  of  the  affection.  Jt 
is  always  increased  by,  but  at  times  is  present  only  on,  movement. 
The  pain  is  remarkable  for  its  severity,  the  majority  of  the  patients 
being  completely  disabled. 

The  location  of  the  pathological  process  in  Silver's  cases  was  a.s 
follows : 

Cervical 0 

Dorsal 4 

Lumbar 31 

Sacral 1 

Dorso-lumbar 5 

Dorso-lumbar-sacral 1 

Lumbo-sacral 7 

Not  definitely  stated 5 

Thus  in  83  per  cent,  of  the  reported  cases  the  lumbar  region  was 
affected. 

Local  Changes. — A  distinct  swelling  in  the  affected  region,  on 
either  one  or  both  sides  of  the  spine,  was  present  in  14  cases,  or 
26  per  cent.;  this  was  associated  with  redness  in  3,  and  with 
increased  local  temperature  in  4  cases.  Tenderness  was  noted  in 
29  cases,  54  per  cent.  Kyphosis  is  stated  as  present  in  15  cases  of 
the  series.     Scoliosis  occurred  in  7  cases. 

The  Widal  test  was  made  in  14  cases;  it  was  positive  in  12  and 
negative  in  2.  In  one  of  the  two  negative  cases  a  blood  culture 
revealed  a  paratyphoid  infection,  wliile  the  other  case  was  not  so 
tested. 

The  evidence  is  all  in  favor  of  the  affection  being  a  spondylitis 
or  a  perispondylitis,  and  that  periostitis,  chondritis,  osteitis,  and 
osteomyelitis  may  occur. 

In  the  same  periodical  that  contains  this  extended  analysis  of 


250  COMPLICATIOXS  Dl'RIXG  COXVALESCENCE 

this  large  series  of  cases  is  a  verv  complete  report  of  two  cases  by 
T.  Halsted  Meyers. 

Since  Silver's  article  appeared  Francis  W.  White^  has  reported  a 
case  that  came  under  his  care  ami  added  to  the  list  made  by  Silver 
several  cases  recently  published.  The  number  of  cases  collected 
by  Wliite  being  74. 

One  of  the  most  recent  contributions  to  the  subject  is  by  Thomas 
McCrae,  of  the  Johns  Hopkins  Hospital.  He  presented  a  most 
important  paper  on  "Typhoid  and  Paratyphoid  Spondylitis,  with 
Bony  Changes  in  the  ^Vrtebra*,"  at  the  meeting  of  the  Association 
of  American  Physicians  in  Washington  in  ]May,  1906,  and  pub- 
lished in  the  December  number  of  the  American  Journal  of  the 
Medical  Sciences  of  that  year.  He  states:  "There  may  be  both 
a  spondylitis  and  a  perispondylitis.  As  Gibney  suggested  in 
1.SS9,  it  may  be  an  acute  inflammation  of  the  periosteum  and 
the  fibrous  structure  which  hokl  the  spine  together.  Arthritis  of 
the  vertebral  joints  is  a  possibility,  but  arthritis  of  any  joint  is 
very  rare  in  typhoid  fever." 

Leonard  W.  Ely,^  in  presenting  an  elaborate  report  of  a  case 
studied  by  him,  referred  to  the  summary  and  analysis  of  26  cases 
by  F.  T.  Lord  in  the  Boston  Medical  and  Surgical  Journal  for  June 
26,  1902,  and  to  tliis  number  Dr.  Ely  added  three  cases  from 
the  literature  and  the  one  under  his  personal  care.^ 

Neuroses. — Sometimes  neurotic  patients,  particularly  women, 
suffer  from  hysterical  attacks  of  causeless  weeping  while  con- 
valescence progresses,  and  in  a  case  under  the  writer's  care,  during 
convalescence,  a  strong  and  hearty  man,  a  member  of  the  city 
fire  department,  cried  like  a  cliild  whenever  one  of  liis  fellows  came 
to  visit  him. 

Severe  hysteria  sometimes  complicates  convalescence  in  typhoid 
fever.  Thus,  Simpson*  records  the  case  of  a  woman  who  was  sud- 
denly seized  with  unconsciousness  and  rigidity  during  convalescence; 
she  was  confined  to  bed  for  nine  years,  but  had  regular  attacks  on 

>  White.     Journal  of  tlie  American  Medical  Association,  February  13,  1909. 
'  Ely.     New  York  Academy  of  Medicine,  November  21,  1902. 

'  .\n   elaborate  article    upon  this  subject   by  Fluss  will  be  found  in  Centralblatt  f.  die 
Grenzgebiete  der  Medizin  und  Chirurgie,  1905,  viii,  645. 
■•  Simpson.     Edinburgh  Medical  Journal,  January,  1896. 


NERVOUS  SYMPTOMS   FOLLOWING  TYI'IIOIh   VKVEU     2:j 

each  succeedini^' Siinduy,  Uicdiiy  on  wliidi  (he  (ir.sl.  ii(f;ick  offurrcd. 
Constant  vomiting  was  also  present. 

A  condition  of  very  great  rarity  after  entcrif  \i-\i-v  is  tct;iriy. 
Janeway  has  reported  cases  coming  on  during  the  height  u'i  ty[>hoid 
fever  on  the  tenth  and  twenty-fourth  days. 

l^SEUDOHYPERTROPnic  MUSCULAR  changes  have  been  recorded 
as  occurring  after  typh(M(l  fever  l)y  Lasage,'  The  patient,  a  man, 
aged  twenty-seven  years,  was  seized  on  the  nineteenth  day  of  the 
attack  with  acute  pain  in  the  left  tliigh  and  with  other  symptoms, 
which  caused  a  diagnosis  to  be  made  of  plilegmasia.  Swelh'ng  of 
the  Hmb  did  not,  however,  disappear,  and  several  months  later  it 
was  found  to  be  greatly  increased,  the  hypertrophy  involving  the 
muscular  masses,  which  were  larger  and  firmer  than  in  the  right 
leg,  although  the  electrical  reactions  were  not  impaired,  nor  were 
the  reflexes.  Exercising  the  muscles  on  this  side  produced  cramp- 
hke  contractions.  At  the  time  the  case  Avas  reported  the  condition 
had  persisted  for  two  years. 

The  following  references  to  nervous  and  muscular  lesions  com- 
plicating typhoid  fever  from  Ross  and  Bury's  monograph  may  be 
of  interest  in  this  connection : 

Meyer.  Die  Elektricitdt  auf  Praktische  Meclicin,  Berlin,  1861, 
p.  311. 

Leudet.  "Remarques  sur  les  Paralysies  Essentielles  Consecu- 
tives  a  la  Fievre  Typhoide,"  Gaz.  Med.  de  Paris,  1861, 

Imbert-Gourbeyre.  "Recherches  Historiques  sur  les  Paralysies 
Cons^cutives  aiLX  Maladies  Aigues,"  Gaz.  Med.  de  Paris,  1861. 

Handfield-Jones.  "Abstract  of  a  Clinical  Lecture  on  a  Case  of 
Paralytic  Contracture  after  Fever,"  Medical  Times  and  Gazette, 
1867,  p.  390. 

Murchison.  A  Treatise  on  the  Continued  Fevers  of  Great 
Britain.     Second  edition,  1873,  p.  225. 

Teale  and  Morven,  quoted  by  Xothnagel.  Deutsche  Archiv  f. 
klin.  Med.,  1872. 

Rehn.  "Ein  Fall  von  Lahmung  der  Glottiserweiterer  nach 
Typhus  Abdominalis,"  Deutsch.  Arch.  f.  klin.  Med..  Bd.  x-^'iii. 
p.  136. 

1  Lasage.      Revue  de  Medecine,  Xovember  10,  1SS9. 


252  COMPLICATIOXS  DURIXG  CONVALESCENCE 

1  ^andouzy.    Dcs  Parah/slcs  (hiii.s  lis  Maladies  .  1  i(jucs,  Paris,  1880. 

Bauinler  (C),  "Ueber  Liihmung  des  Musculus  Serratus  Anticus 
major  iiacli  Beobaclitungen  an  Cinem  Fall  von  IMultiplen  Atro- 
pisclien  Liimunoen  ini  Gefolge  von  Typhus  Abdominalis,"  Deuisch. 
Archivf.  klin.  Med.,  1880,  vol.  xxv.  p.  305  to  324. 

Stintzing  (R.).  "Typhus  Abdominalis  mit  Nachfolgender  Atro- 
pischer  Liihrnung,"  Aeizfl.  Lit.  BL,  ^Mimchen,  1SS3,  vol.  xxx.  p.  4. 

Bartholow  (R.).  "Enteric  Paraplegia,"  Medical  News,  Phila- 
delphia, 1SS3,  vol.  xliii,  p.  609. 

Rondot  (E.).  "Contribution  a  I'Etude  des  Paralysies  qui  Sur- 
viennent  dans  la  Fievre  Typhoide;  Paraplegic  et  Amyotrophia 
^Nlyelopathiques  d'Origine  Typhoidique,"  Gaz.  Hebd.  de  Sci.  Med. 
de  Bordeaux,  1885,  vol.  vi,  p.  446. 

P^liotis.  De  la  Nevrite  Peripherique  du  Cubital  Consecuiif  a 
la  Fievre  Typhoide,  Paris,  1885,  These. 

Raymond.  "Deux  Cas  de  INIy^lite  Ascendante  Observes  pen- 
dant la  Convalescence  de  la  Dothidnent^rie,"  Revue  de  Medecine, 
1885,  p.  648. 

Courtade  (D.).  "Des  Paraplegics  Survenant  dans  le  Cours  ou 
pendant  la  Convalescence  de  la  Fievre  Typhoide,"  L'Encephale, 
Paris,  1886,  vol.  vi.  p.  431. 

Wurtz.  "Note  sur  un  Cas  de  Nevrite  Tibial  Anterieur  Siu-venue 
dans  le  Cours  d'une  Fievre  Typhoide,"  L'Encephale,  1886. 

Buzzard  (T.).     Paralysis  from  Puerperal  Neuritis,  1886,  p.  102. 

Bassi  (U.).  "Nevrite  Multipla  Consecutiva  a  Febbre  Tifoide," 
Rev.  Veneta  di  Sc.  Med.,  Venezia,  1887,  vol.  vi,  p.  585. 

Oppenheim  and  Siemerling.  "Beitrage  zur  Pathologic  der 
Tabes  Dorsalis  und  der  Peripherischen  Nervenerkrankung," 
Archiv  fiir  Psychiatrie,  1887,  p.  709. 

Puybaret  (J.  A.  C).  Contribution  a  V Stride  des  Paralysies  dans 
la  Fievre  Typhoide,  Bordeaux,  1887,  Thesis. 

Stadelmann.  "Ueber  einen  Eigenthiimlichen  jNIikroskopischcn 
Befund  in  den  Plexus  Brachialis  bei  einer  Neuritis  in  Folge  von 
Typhus  Abdominalis,"  Neurol.  Centralb.,  1887,  p.  285. 

Gowers.  A  Manual  of  Diseases  of  the  Nervous  System,  vol.  ii, 
p.  824. 

Stoney  (W.).      "Paralysis  of  Extensor  Muscles  of  Thigh  fol- 


THE  SKIN  IN   Till':  i^TACK  OF  COW ALhSCENCE        25,'^ 

lowinrf  Ent(!ric  Fo.'vcr,"  Medical  Ptchh  mid  ('ircuLar,  JSSli,  X.  S., 
vol.  xlvii,  p.  502. 

Kel)lcT  (J.J.  " J*().st-(.y|>lioi(l  Paralyses/'  Cincinnati  Lanceir 
Clinic,  1889,  N.  S.,  vol.  xxiii,  p.  '4^). 

Longstreth  (M.).  "Neuritis  after  Typhoid;  Klicurriatic  Neu- 
ritis/' Phy.rician  and  Surgeon,  Ann  Arbor,  ]\Iieli.,  1887,  vol.  ix, 
p.  201. 

Comte.  "Un  Cas  dc  Paralysie  G(?n(5ra]isde  k  la  Suite  de  la 
Fifevre  Typhoide,"  Poilcau  Med.,  Poitiers,  1887,  tome  ii,  p.  ]]'-j. 

Schmidt  (F.).  "Ueber  Neuritsche  I>ahmungen  nach  Abdomi- 
naltyphus,"  Hamberg,  1891. 

Pal.     "ITebcr  Multiple  Neuritis/'  Wicn,  189],  p.  37. 

The  Skin  in  the  Stage  of  Convalescence.— Aside  from  boils, 
carbuncles,  and  gangrene,  which  may  appear  at  this  time,  and 
which  have  been  discussed  under  the  heading  of  the  well-developed 
stage  of  the  malady,  we  find  as  the  most  common  complication 
to  be  erysipelas,^ 

According  to  Liebermeister,  this  complication  occurs  generally 
during  convalescence  and  seldom  at  the  height  of  the  disease. 
He  believes  it  may  be  a  dangerous  factor,  although  in  1420  cases  of 
typhoid  fever  in  Basel,  erysipelas  appeared  only  ten  times,  and  all  of 
the  ten  recovered.  Eight  were  cases  of  facial  erysipelas.  Two  others 
developed  the  disease  about  bed-sores.  In  other  words,  erysipelas 
occurred  in  less  than  1  per  cent,  of  these  cases.  Griesinger"  states 
that  it  occurs  in  about  2  per  cent.  Taupin  (1839)  speaks  of  two 
cases  of  erysipelas  of  the  face  occurring  in  children  suffering  from 
typhoid  fever. 

The  following  cases  occurred  within  a  period  of  six  weeks  of 
each  other  in  the  wards  of  St.  Agnes'  Hospital  under  the  care  of 
the  senior  author.  The  first  case  was  separated  from  the  second 
by  an  interval  of  five  weeks,  and  the  second  from  the  tliird  by  less 
than  a  week.  They  were  all  in  the  same  ward,  but  occupied  beds 
at  least  twenty  feet  apart.     The  fu'st  case  was  as  follows: 

Maggie  T.,  aged  twenty-two  years,  was  admitted  December  16, 
1890,  with  a  history  of  chi-onic  suppuration  of  the  middle  ear. 

1  See  article  by  Hare  and  Patek  in  the  Medical  News,  January,  1S91. 
^  Griesinger.     Infectionskrankheiten. 


254  COMPLICATIOXS  DCRIXG  CO.WALESCENCE 

She  was  treated  at  the  dispensary,  and  rapidly  improved,  being 
discharged  on  December  23.  On  January  8,  1891,  she  was  re- 
admitted with  well-defined  symptoms  of  a  mild  attack  of  typhoid 
fever,  which  ran  a  short  course,  the  patient  being  discharged  on 
January  30.  On  February  2  she  entered  the  house,  complain- 
ing of  pain  in  the  abdominal  region  and  in  the  knees  and  elbows; 
the  pains  were  not  very  severe,  but  the  joints  were  somewhat 
swollen;  the  tongue  was  brown  and  dry,  and  all  the  symptoms, 
such  as  the  stools,  the  rose-colored  spots,  the  characteristic  tempera- 
ture, and  appearance  of  the  patient,  pointed  to  a  relapse  of 
typhoid  fever,  although  at  first  the  case  was  treated  as  one  of 
rheumatism.  The  temperature  did  not  exceed  103°,  and  the 
patient  went  through  a  moderately  severe  attack  of  typhoid  fever 
without  complication,  except  for  very  marked  enlargement  of  the 
glands  of  the  neck,  which  was  relieved  very  promptly  by  the  use 
of  an  ice-collar.  On  IMarch  5  a  well-defined  erysipelatous 
swelling  appeared  over  the  left  side  of  the  face,  about  the  temples 
and  malar  bones,  and  gradually  extended  over  the  entire  face  and 
part  of  the  scalp.  The  eyes  were  completely  closed,  and  the  lips 
very  much  swollen.  The  mouth  was  very  painful,  being  covered 
with  sores  to  such  an  extent  that  it  was  impossible  for  the  tongue 
to  be  protruded,  and  it  was  impossible  for  food  to  be  taken.  The 
throat  was  very  dry,  and  a  spray  was  used  as  a  mouth-wash. 
The  ordinary  treatment  for  typhoid  fever  was  at  once  with- 
drawn, and  the  patient  was  put  on  thirty  drops  of  the  tincture  of 
chloride  of  iron,  three  times  a  day.  Under  this  treatment  she 
improved,  and  by  ]March  16  all  inflammation  had  entirely  dis- 
appeared, leaving  only  some  swelling,  which  in  the  course  of  the 
next  two  weeks  entirely  passed  away.  The  patient  during  this 
time  continued  to  manifest  symptoms  of  typhoid  fever,  and  was 
unable  to  leave  her  bed  on  account  of  this  disease  for  three  weeks 
after  the  erysipelas  had  disappeared.  Entire  recovery  eventually 
took  place. 

The  second  case  was  that  of  A.  E.,  a  female,  aged  twenty  years, 
who  was  admitted  to  my  wards  with  all  the  early  symptoms  of 
enteric  fever,  which  developed  into  a  moderately  severe  attack, 
but  was  without  any  extraordinarily  severe  symptoms.  It  was 
estimated  that  at  the  time  the  erysipelas  developed  she  was  in  the 


77/ A'  -SAViV  IN  TiiK  STAf,'/':  OF  coNV aij:hcI':nci<:      255 

third  week  of  the  typhoid  fever.  At  tlie  f>n.scf  of  th(;  ery.sijM-la.s 
there  was  u  cliill  followed  l)y  a  rise  of  teinperatiirf  f<f  2"^,  and 
followed,  after  the  use  of  a  cold  l);illi,  hy  ;i  f;ill  (o  (Ik-  tcmpfradire 
course  previously  })ursu('d.  'i'he  ei-ysijK'las  he^an  ain^ut  the  bridge 
of  the  nose  and  extended  raj)idly  over  the  entire  face  back  to  the 
ears  and  to  the  margin  of  the  hair,  whence  it  ceaserl  to  spreafl. 
The  eyes  were  closed  ;iiid  tlic  li|)s  miicii  suollcn.  An  (•.\;iiiiiii;itioii 
of  the  serum  withdrawn  hy  a  lancet  showed  the  charaetcrisdc 
streptococci  of  erysipelas.  Under  the  use  of  large  doses  of  tinc- 
ture of  the  chloride  of  iron  and  an  application  of  ichthyol  c>int- 
ment,  recovery  rapidly  took  place.  The  mouth  was  unusually  foul 
and  dry,  but  no  delirium  was  present.  It  could  not  be  noticed  that 
the  complication  in  any  way  increasefl  the  gravity  of  the  case. 

The  third  case  was  as  follows :  A  w^oraan,  aged  nineteen  years,  a 
Swede,  was  admitted  in  the  early  stages  of  typhoid,  which  ran 
a  mild  course,  devoid  of  delirium  or  any  symptoms  of  importance, 
except  that  on  an  afternoon,  about  the  middle  of  the  third  week 
of  her  illness,  she  developed  a  sudden  rise  of  temperature  to  104°, 
followed  at  once,  on  the  use  of  cold  bathing,  by  a  fall  to  98°,  with 
loss  of  the  pulse  at  both  wrists.  As  a  precautionary  measure,  she 
was  treated  as  if  suffering  from  intestinal  hemorrhage,  and  soon 
rallied,  developing  during  the  next  twelve  hours  a  typical  patch 
of  erysipelas  on  the  right  side  of  the  nose  and  over  the  malar 
bone.  There  was  no  further  disturbance  of  the  typhoid  tempera- 
ture, and  the  disease  remained  limited  to  that  side  of  the  face. 
The  patient  was  treated  ^^^th  iron  and  ichthyol. 

By  far  the  most  exhaustive  study  which  we  have  found  con- 
cerning erysipelas  as  a  complication  of  typhoid  fever  is  that  of 
Gerente.^  According  to  this  author,  the  complication  comes  on 
in  one  of  every  sixty-one  cases,  which  would  give  a  much  higher 
percentage  than  that  of  Liebermeister  or  Griesinger.  Gerente 
states  that  females  are  more  commonly  affected  than  males,  which 
is  a  curious  fact,  because  males  are  more  exposed  and  more  fre- 
quently have  typhoid  fever.  In  regard  to  the  period  of  the  disease 
at  which  erysipelas,  as  a  rule,  appears,  Gerente  states  that  it  is 
generally  after  the  twenty-first  day,  and  he  also  believes  that 
some  epidemics  of  typhoid  are  peculiarly  liable  to  this  complica- 

1  Gerente.     Th^se  de  I'Ecole  de  M^decine,  1883-84,  t.  i. 


256  COMPLICATIOXS  DUIilXG  CONVALESCENCE 

tion.  The  followino;  conclu,sion.s  of  Gerento,  liowever,  embody 
most  of  his  statements: 

Outside  of  the  question  of  contagion,  it  appears  to  be  most  fre- 
quent in  the  grave,  adynamic  forms  of  typhoiil,  antl  in  those  of 
long  chn-ation;  it  appears  to  be  most  frequent  in  lymphatic  subjects. 

While  observed  at  all  stages  of  typhoid  fever,  erysipelas  shows 
itself  especially  ami  almost  exclusively  during  the  last  period  and 
during  convalescence. 

Under  these  circumstances  erysipelas  produces  a  marked  ameli- 
oration in  the  general  as  well  as  in  the  local  symptoms. 

The  appearance  of  facial  erysipelas  in  the  course  of  typhoid 
fever  is  of  grave  prognosis  (sixteen  deaths  out  of  thirty-six  cases); 
this  gravity  lies  less  in  the  erysipelas,  which  most  frequendy  is 
benign  in  itself,  than  in  the  poor  general  condition  of  the  patient, 
the  secondary  infection  being  an  indication  of  this  condition. 

The  complication  consists  in  a  simple  coincidence  favored  by 
debility,  the  result  of  the  primary  and  principal  disease. 

We  think  the  statement  that  erysipelas  seriously  influences  the 
prognosis  in  all  cases  too  sweeping.  Thus  there  are  cases  on 
record  in  wliich  the  onset  of  the  acute  disease  has  not  in  any  way 
retarded  convalescence.  If  the  disease  becomes  phlegmonous  the 
prognosis  is,  of  course,  very  grave;  but  if  the  inflammation  is 
capable  of  undergoing  resolution  the  prognosis  is  good. 

Eysipelas  of  the  face  is  rarely  met  with  dming  the  course  of 
typhoid  fever.  We  have  found  it  recorded  in  64  out  of  3910  cases, 
which  is  about  1  to  61.  These  figures  are  derived  from  the  fol- 
lowing statistics. 

Typhoid  fever    Erysipelas 

cases.  cases. 

Chomel 130  4 

Louis 134  .3 

Forget 92  1 

Jenner 05  2 

De  Larroque 105  4 

Zuelzer 84  3 

Liebermeister 1420  10 

Zuccarini 480  18 

Griesinger 500  10 

Murchisoni 900  9 

Total 3910  64 

1  The  number  of  Murchison's  cases  is  not  strictly  correct. 


77//';  ,S7\:/yV   IN   T/f/'J  STAdK  OF  CON  V  A  f.  ESC  FN  CI-:         257 

'V\\i\  (jiUisUon  ;i,s  (o  llic  j);i-lli  \\\  wliidi  vt)\\\;\i^\i,\\  find  ,  ciilijinfo 
has  l)een  much  (h'scnssed,  but  the  opinion  of  (iri<;.siM^<;r  i.s  f^fiicr- 
ally  ac(;optc(l.  lie  believes  tliuL  IIk;  ^<i  ins  njdn  ei)lrane(;  by  inf;aiis 
of  the  inflammation  of  tiie  frontal  or  sj)bcn()i(hil  sinuses,  and  also 
when  ulceration  of  the  bucciil  nnuons  mcmlirane  exists.  Zenler 
also  points  out  tliat  in  his  own  cases  and  in  those  of  Znccarini 
the  erysipelas  started  in  the  stomatitic  spots  and  ulcerations  in 
the  mouth. 

In  all  our  cases  the  patients  complained  very  much,  both 
before  and  after  the  attack  of  erysipelas,  of  the  soreness  of  their 
mouths. 

The  following  cases,  which  have  been  reported  in  addition  to 
the  three  of  Gerente,  are  interesting. 

Ai'mieux^  reports  the  case  of  a  soldier  in  wliom  typlioid  syni]>- 
toms  set  in  on  September  18,  1881,  with  pain  in  the  head,  vertigo, 
abdominal  tenderness,  pain  in  the  right  iliac  fossa,  and  an  elevated 
temperature.  On  October  4  a  complication  arose  in  an  otorrhoea 
which  by  the  22d  was  growing  steadily  worse,  so  that  the  patient's 
condition  was  critical.  Now  facial  erysipelas  made  its  appearance, 
beginning  in  the  auditory  canal.  Early  in  November  osteitis  of 
the  humerus  set  in,  and  the  patient  died  on  November  9. 

Thielman^  reports  the  case  of  a  man,  aged  thirty  years,  brought 
into  the  hospital  in  an  unconscious  condition.  The  right  ear,  eye- 
lids, nose,  greater  part  of  the  face,  and  forehead  were  covered  with 
an  erysipelatous  eruption.  The  tongue  was  dry  and  brown,  there 
was  pain  in  the  ileocecal  region,  and  the  Hver  was  painful  and 
enlarged.  The  fever  was  recognized  as  typhoid,  and  the  patient 
put  upon  calomel.  The  patient  was  in  a  delirious  condition,  but 
on  the  following  day  there  was  a  slight  remission,  and  he  became 
partly  conscious.  The  erysipelas  was  seen  to  be  spreading  farther 
over  the  face,  but  leaving  its  original  seat.  There  was  delirium 
the  following  night  and  semiconsciousness.  Desquamation  set  in 
on  the  right  side  of  the  face,  the  eruption  extending  on  the  left. 
The  pulse  grew  stronger,  but  the  tongue  was  still  brown  in  the 

I  Armieux.     Rev.  Med.  de  Toulouse,  1875,  ix.  42. 

=  Thielman.  Med.  Jahresbuch  v.  Peter-Paul  Hospital  in  St.  Petersburg  (1S40.  1841), 
142,  147. 

17 


258  COMPLICATIOXS  DURIXC  COXYALESCENCE 

centre.  The  patient  was  noticed  to  ])e  troubled  with  occasional 
cough,  and  the  respirations  were  somewhat  more  frecjuent.  Exam- 
ination showetl  a  hypostatic  congestion  of  the  lungs.  The  condi- 
tion became  critical,  but  was  relieved,  and  the  patient  gradually 
improved,  being  dismissed  as  cured  on  the  thirty-fifth  (hiy  after 
admission. 

Berthoud'  re])orts  a(juestional)le  case  of  a  soldier  who  had  typhoid 
fever  of  a  nu'niiigeal  type.  The  typhoid  fever  was  declining,  but 
convalescence  was  tardy,  and  his  general  condition  was  unsatisfac- 
tory. At  this  time  the  scrotum  became  tumefied  and  red,  the  red- 
ness spreading  to  the  inguinal  regions,  while  the  general  condition 
became  very  poor.  The  scrotum  was  triple  its  natural  size,  red, 
moderately  warm,  tender,  not  very  painful,  but  oedematous,  the 
redness  extending  to  the  right  and  left  inguinal  regions  as  far  as 
the  anterior  superior  spinous  process,  and  also  to  the  internal 
aspect  of  the  thigh.  The  skin  in  these  parts  was  swollen  })ut  soft, 
and  the  color  persisted  on  pressure.  On  the  next  day  there  was 
no  amelioration  of  the  symptoms,  but  a  very  small  area  of  necrosis 
appeared  on  the  scrotum,  which  was  treated  by  the  application  of 
the  cautery.  On  the  following  day  the  necrosis  seemed  to  be 
arrested  and  the  scrotum  reduced  in  size.  The  general  condition, 
however,  remained  alarming.  Six  days  later  the  patient  died,  after 
a  subdelirium  of  four  hours.  The  autopsy  showed  that  the  iliac 
and  renal  veins  were  involved  in  a  plastic  and  suppurative  inflam- 
mation, a  case  of  erysipelas  in  the  veins.  The  conclusion  reached 
was  that  the  redness  of  the  skin  and  infiltration  were  due  purely 
to  mechanical  causes,  viz.,  the  stagnation  of  the  blood. 

Freud enberger"  has  recorded  two  cases,  in  one  of  which  erysip- 
elas appeared  suddenly  on  both  ears  in  the  course  of  typhoid  fever, 
without  unfavorable  symptoms.  On  the  following  day  a  chill  and 
rapid  advance  of  the  disease  took  place.  The  typhoid  fever  was 
now  considered  as  declining,  but  the  prognosis  grave,  because  of 
the  erysipelas.  In  the  second  case,  facial  erysipelas  suddenly 
appeared  during  convalescence  from  typhoid  fever,  although 
the   temperature   was    already   quite  low.      The    fever    became 

1  Berthoud.     Gaz.  des  Hop.  de  Paris,  1848,  v.  29. 

-  Freudenberger.     Aerztl.  Intelligenzblatt,  Miinchen,  1880,  xxvii,  37. 


Till':  SKIN  IN   TIII'J  STACH  O/-'  ('f)N  \.\  Li:SC ENC I']        250 

high  ii|ji;ii,iii,  hiil,  was  easily  iiidiicnccd  In  Jinlipyrclirs.  'J'lic  j^iilse 
was  ]4(). 

Potaiii'  reports  a  case  of  erysipehis  coining  f>n  (hiring  convales- 
cence from  typiioid  fever,  which  was  acconi|)aiiic(l  hy  a  severe  rliill 
and  fever.  The  erysipelas  hegan  in  (lie  |)liaiyn.\  and  pidaic,  ;iud 
did  not  affect  the  tonsils.  On  the  next  day  die  iidhiiiiinwnoji 
appeared  at  the  corners  of  the  mouth  and  on  the  face. 

Finally,  Martinez'^  reports  the  following  cases:  A  girl,  agerl 
twenty  years,  belonging  to  the  lower  class,  of  lymphatic  tenip<ra- 
ment,  with  very  irregular  menstruation,  which  was  often  almost 
absent,  was  taken  ill  with  typhoid  fever.  The  symptoms  were 
obscure  at  the  onset  of  the  disease,  but  the  most  prominent  mani- 
festation was  an  erysipelatous  inflammation  of  foot  and  leg.  On 
the  fourth  day  the  erysipelas  was  marked;  there  was  great  fever, 
cephalalgia,  and  other  typhoid  symptoms,  such  as  weakness,  gur- 
gling in  the  right  iliac  fossa,  dryness  and  tremblings  of  the  tongue, 
sordes  on  the  teeth,  great  stupor,  delirium,  and  a  frequent  and 
small  pulse.     Death  took  place  after  some  days. 

Whether  the  erysipelatous  trouble  had  anything  to  do  with  the 
causation  of  the  typhoid  symptoms  or  not,  Martinez  does  not  state, 
but  he  mentions  the  case  of  another  woman  in  whom  an  extensive 
erysipelatous  inflammation  of  the  face  and  scalp  produced  cerebral 
symptoms,  fever,  etc.,  but  they  were  not  so  pronounced  as  to  be 
confounded  with  those  caused  by  true  typhoid  fever,  as  in  the 
present  instance.     In  this  case  the  patient  recovered. 

It  is  an  interesting  fact  in  this  connection  that  Silvestrini''  has 
met  with  two  cases  of  facial  erysipelas  in  typhoid  fever,  in  which 
the  inflammation  was  found  to  be  due  not  to  streptococci,  but  solely 
to  the  bacillus  of  Eberth.  He  asserts  that  Klebs  and  Reiner  have 
met  with  similar  cases. 

Sweating. — Very  often  in  the  last  week  of  defervescence  and 
in  convalescence  the  patient  suffers  from  colliquative  sweating  of 
a  marked  type.  It  has  seemed  to  us  that  in  these  cases  the  flow  of 
sweat  was  often  an  effort  at  elimination. 

1  Potain.     ErysipHe  de  la  Face  Consecutif  a  la  Fievre  Tj-plioide.  Gaz.  des  Hop.  de  Paris, 
1880,  liii,  1106. 

2  Martinez.     La  Espaiia  Mi^diea,  Madrid,  Mare'i  1,  1860,  p.  135. 

3  Silvestrini.     La  Riforma  Medica,  1894,  196,  197. 


260  COMPLICATIONS  DURING  CONVALESCENCE 

Tauj)in'  (ells  us,  in  an  article  written  as  long  ago  as  1S39,  that 
in  children  it  is  common  to  meet,  during  convalescence,  with  very 
abundant  sweating  of  the  upper  part  of  the  body,  while  the  lower 
parts  remained  dry,  and  that  ehiklren  convalescing  from  typhoid 
fever  may  he  attacketl  by  an  eruptive  fever.  He  also  speaks  of 
cases  of  typhoid  fever  attacked  by  scarlet  fever,  sinallpox,  and 
measles,  due,  in  all  probability,  to  the  lack  of  isolation  in  fever 
wards  in  those  days.     (See  Skin  Lesions  in  Early  Stages.) 

Desquamation  of  the  skin  during  typhoid  fever  was  noted  long 
ago  In'  Louis,  but  few  references  to  this  condition  are  found  in 
literature.  Text-books  of  medicine  make  few  references  to  this 
complication,  although  several  writers  note  the  condition  of  desqua- 
mation which  follows  sudamina.  Striimpell  speaks  of  desquama- 
tion dm-ing  typhoid,  and  Osier,  in  the  latest  edition  of  his  text-book 
on  Medicine,  states  that  branny  desquamation,  particularly  among 
children,  is  not  rare,  and  that  occasionally  the  skin  peels  off  in  large 
flakes.  In  his  extensive  experience  in  typhoid  fever,  Osier  saw 
but  four  cases  of  distinct  desquamation  of  the  skin.  Dreschfeld, 
in  Allbutt's  System  of  Medicine,  says  that  a  desquamation  of  fine 
branny  scales  is  often  seen  toward  the  end  of  the  fever  or  during 
convalescence.  Weill,^  of  Lyons,  noted  desquamation  33  times  in 
37  cases  of  typhoid  fever  in  children.  Comby^  also  was  surprised  to 
discover,  when  he  gave  the  matter  attention,  that  of  18  children  sick 
of  typhoid  fever,  each  one  suffered  from  desquamation  during  con- 
valescence. Riesman*  has  recently  called  particular  attention  to 
this  complication  in  reporting  two  cases  of  extensive  desquamation 
which  he  observed. 

A  profuse  bran-like  desquamation  of  the  skin  is  frequently  met 
with  in  patients  convalescing  from  typhoid  fever.  We  have  seen 
this  again  and  again,  and  Comby^  speaks  of  it  as  a  state  met 
with  in  the  convalescent  period  in  children.  It  is  particularly 
common  in  bathed  cases. 

Coulon^  has  recorded  a  case  of  typhoid  fever  in  a  child,  aged  ten 

'  Taupin.     Journal  des  Connaissance  Medico-Cliirurgicale,  1839,  No.  7. 

=  Weill.     Gaz.  des.  Hopitaux,  1896,  p.  232. 

'  Comby.     Ibid.,  p.  315. 

*  Riesman.     Amer.  Jour.  Med.  Sci.,  January,  1904. 

'  Comby.     Gaz.  des  H6pitaux,  1896,  No.  39. 

"  Coulon.     La  Mddicale  Enfantile,  January,  1895. 


THE  ^KIN  IN   TIll<:  STA(JI'J  OF  COS V ALI'SCHXCfC        201 

and  a  half  years,  in  wliicli  (hero  was  geruTal  (h'stjuainud'on  ol"  lh«; 
skin  (luring  convah'scciicc;  previous  to  \hu\  there  iia<i  been  no 
eruption  on  the  skin.  On  (he  other  hjind,  it  is  noteworthy  that 
there  had  been  sore  thront,  alburrn"nuria,  and  o-derna,  so  tFie  ease 
may  have;  Ixh'U  one  of  searh't  fever  rompncafing  (y|»iioid,  and 
without  the  on h nary  rash. 

Amitrano*  lias  recorded  a  ease  of  typhoid  fever  whir  h,  during 
convalescence,  developed  the  searlatiniforrn  rash  which  desf|ua- 
mated.  Marked  meningeal  symptoms  developed  after  the  fever 
subsided,  and  after  descjuamation  was  completed  a  second  ery- 
thema of  the  skin  appeared,  which  was  also  fc^Ilowcd  by  desqua- 
mation. This  case,  ])erhaps,  belongs  to  the  class  of  dermatitis 
exfoliativa.  (See  last  chapter  for  a  discussion  of  typhoid  fever 
complicated  by  eruptive  diseases.) 

Skin  Lesions. — A  somewhat  unusual  lesion  of  the  skin,  result- 
ing from  typhoid  fever,  is  the  development  of  linea;  albicantes. 
Cases  of  this  kind  have  been  reported  by  Troisier,^  and  Manouvriez 
and  Bouchard  have  also  recorded  such  instances.  It  is  stated 
that  they  occm*  most  frequently  in  children  and  young  adults. 
Bucquoy  notes  that  in  boys  these  whitish  lines  have  no  special 
area  of  distribution,  but  in  girls  the  breasts  and  crests  of  the  ilium 
are  the  places  where  they  usually  appear.  Bari^  has  reported  the 
case  of  a  girl,  aged  seventeen  years,  in  whom  these  lines  appeared 
over  the  knuckle-joints  of  each  hand. 

A.  somewhat  similar  condition,  due  to  localized  atrophy  of  the  skin, 
is  recorded  by  Bradshaw'.^  In  his  case  a  girl,  aged  thirteen  years, 
who  suffered  from  typhoid  fever  followed  by  relapse,  and  again  by 
a  second  relapse,  finally  developed  during  convalescence  upon  the 
inner  siu"face  of  the  lower  third  of  the  thigh  a  number  of  hori- 
zontal markings,  some  of  which  partially  siurounded  the  limb; 
they  were  about  one-half  inch  in  \\-idth,  regular  in  contour,  and 
almost  exactly  alike  on  both  legs.  A  similar  condition  has  been 
described  by  Wilkes.^ 

One  of  the  complications  of  lesser  importance,  but  an  extremely 

1  Amitrano.     La  Riforma  Medica,  1896,  No.  146. 

2  Troisier.     Bulletin  et  Memoire  de  la  Society  Medicale  des  Hopitaux,  1S89,  No.  12. 

3  Bradshaw.     Bristol  Medico-Chirurgical  Journal,  July,  1S89. 
*  Wilkes.     Guj-'s  Hospital  Reports,  1861. 


262  COMPLICATIOXS  DUIUXU  COXVALESCENCE 

common  and  at  times  a  troublesome  one,  is  alopecia  following 
typhoid  fever.  There  is  always  a  tendency  for  the  hair  to  lose  its 
vigor  in  every  continued  fever  and  particularly  in  typhoid  fever, 
in  which  the  fever  is  so  prolonged.  It  has  been  noted  by  many 
writers,  but  particularly  by  Little,*  of  ^Montreal,  that  if  the  hair  is 
cut  early  in  the  attack  much  of  the  danger  of  aloj)ecia  following  the 
attack  is  ilone  away  with,  and  the  growth  of  hair  which  follows 
the  illness  seems  of  better  (juality  than  before. 

A  very  rare  condition  coming  on  during  convalescence  in  typhoitl 
fever  is  reported  by  Leudet,'  namely,  the  condition  of  painful 
cedema  of  the  thorax.  Pain  was  first  felt  in  the  neighborhood 
of  the  thyroid  gland,  then  in  the  shoulder-blade;  later,  a  circum- 
scribed a\lema  of  the  left  side  of  the  thorax  developed,  which  was 
not  reddened,  but  was  painful  to  the  touch.  There  was  no  fever 
and  no  albimiinuria.  The  condition  lasted  for  four  days  in  its 
fully  developed  stage,  but  had  disappeared  entirely  by  the  twelfth  day. 

There  have  also  been  recorded  two  cases  in  which  the  oedema 
was  localized  to  the  abdominal  wall,  and  were  noticed  in  the  fifth 
and  sixtli  weeks  of  the  disease  by  Walter.^ 

The  Thyroid  Gland. — The  thyroid  gland  ma}-  undergo  suppu- 
ration as  a  result  of  typhoid  fever,  as  it  may  in  other  infectious 
processes.  Thus,  Pinchaud^  has  recorded  such  a  complication  of 
convalescence,  and  Forgue,^  a  INIajor  in  the  French  Army,  has 
matle  a  contribution  on  this  condition.  Other  observers  have 
recorded  a  similar  state  complicating  the  other  infectious  diseases, 
and  the  view  is  generally  held  that  the  gland  becomes  infected 
from  the  entrance  of  the  bacillus  into  the  blood,  by  wliich  it  is 
carried  to  the  thyroid  gland.  Testevin,**  a  Major  in  the  French 
Army,  under  the  title  of  "Thyroidite  Infectieuse  Suppur^e," 
discusses  the  literature  of  the  subject.  From  his  paper  it  is  evident 
that  of  all  the  infectious  diseases,  typhoid  fever  is  the  one  which 
most  commonly  causes  this  lesion  in  this  gland,  and,  further,  that 

1  Little.     Montreal  Medical  Journal,  June,  1908. 
^  Leudet.     La  Normandie  M^dicale,  October  1,  1891. 
'  Walter.     American  Medicine,  December,  1908. 

■*  Pincliaud.     Des  Thyroidites  dans  la  Convalescence  de  laFievre  Typhoide,  Paris,  1881. 
'  Forgue.     Contribution  A  1' Etude  de  la  Thyroiditd  Typique,  Arch,  de  M(?d.  et  de  Phar. 
Milit.,  1886,  1,  vii. 

0  Testevin.     Ibid.,  February,  1899,  p.  126. 


JOINT!^  203 

it  is  emphatically  a  consecutive  or  .secori(hiry  iriaiiife.staliort  cliiefly 
met  with  in  convalescence,  iiohcrtson'  has  reptjrted  a  case  of 
thyroiditis  complicating  typhoid,  and  reviews  the  literature,  (juoting 
from  Walther,  who  in  his  Dissertation  in  Leipsic  in  1S90  recorded 
forty  cases  of  thyroiditis  complicating  typhoid.  ''rf)pfer'''  ref>orfs 
three  cases  of  abscess  of  the  thyroid  in  027  antopsies  of  ty[>lioid 
cases.  In  very  rare  instances  the  thyroiditis  develojjs  with  the 
onset,  as  set  forth  by  TaveP  and  Ivaveran.* 

Finally,  it  is  a  noteworthy  fact  that  Chantemesse'  has  f(jiiiid  the 
bacillus  of  Eberth  in  the  pus  of  the  thyroid  gland  and  his  finding.s 
have  been  substantiated  since  that  time  by  many  other  observers, 
among  the  number  being  Schadmosky  and  Valerhos,"  I>ifhtheim- 
Tavel,^  Jeanselme,**  and  Schudmark  and  Vlachos." 

A  case  of  suppuration  of  the  right  lobe  of  a  goitrous  thyroid 
gland  has  been  recorded  by  Spirig/"  in  a  woman,  agetl  twenty-two 
years.  This  complication  arose  after  five  weeks  of  typhoid  fever, 
when  the  disease  was  on  the  decline;  both  the  bacillus  of  Eberth 
and  the  staphylococcus  were  found  in  the  pus.  In  not  a  few 
instances  an  examination  of  the  pus  from  the  abscess  within  the 
thyroid  has  revealed  the  ordinary  pyogenic  micro-organisms, 
staphylococcus  and  streptococcus,  and  it  has  been  noticeable  that  in 
this  class  of  cases  the  condition  has  been  more  unfavorable  in  as 
much  as  the  condition  is  a  part  of  a  general  septicaemia. 

Joints. — Articular  lesions  complicating  convalescence  from 
typhoid  fever  may  be  due  to  direct  infection  \di\\  the  specific 
bacillus,  which  is  rare,  or  to  infection  by  other  organisms.  This 
question  is  ably  considered  in  Dr.  Keen's  monograph,  already 
quoted,  and  does  not  need  to  be  discussed  at  this  point  for  this 
reason. 


1  Robertson.     American  Journal  of  the  Medical  Sciences,  January,  1902, 
-  Topfer.     Munch,  med.  Woch.,  1892. 

3  Tavel.   Ueber  die  Etiologie  der  Strumitis,  ein  Beitrage  zur  Lehre  von  den  Hemato- 
genen  Infectionen,  Bale,  1892. 

''  Laveran.     Revue  de  Chirurgie,  September,  1890,  No.  29. 

5  Chantemesse.   Art.  Fi&vre  Typhoide  in  Traitede  Med.de  Bouchard  et  Charcot,  1891,768. 

6  Schadmosky  and  Valerhos.     W^ien.  klin.  Woch.,  July  19.  1900. 

"  Lichtheim-Tavel.     Ueber  die  Aetiologie  der  Strumitis,  Basel,  1892. 
s  Jeanselme.     Arch,  gen.,  July,  1893. 

9  Schudmark  and  Vlachos.     Wien.  klin.  Woch.,  1900,  No.  29. 
^'^  Spirig.     Correspondenzblatt  fiir  Schweizer  Aerzte.  February  1,  1892. 


2G4  COMPLICATIOXS   DIRIXG  CONVALESCENCE 

Robin  and  Lereckle*  have,  however,  called  attention  to  the  inter- 
estino-  fact  that  acute  articular  intlannnation  is  .sometimes  met  with 
in  typhoid  fever,  and  believe  it  to  be  rheumatic  in  some  cases. 
On  the  other  hand,  in  the  great  majority  of  instances  the  joint 
affection  is  not  due  to  acute  articular  rheumatism,  but  is  simply 
an  evidence  of  the  septic  process  associated  with  the  typhoid  fever. 
Great  care  should  be  exercised  by  the  physician  that  articular 
inflammation  does  not  mislead  him  into  an  erroneous  diagnosis. 

rorter  reports  two  cases  of  typhoid  coxitis,  and  publishes  radio- 
graphs of  the  condition.  The  first  sign  w^as  inability  of  the  patient 
to  lie  on  the  affected  side,  and  there  w^as  a  tendency  to  keep  the 
thigh  flexed;  also  a  tendency  to  spontaneous  dislocation  of  the  hip. 

As  is  well  known,  dislocations  have  been  recorded  in  consider- 
able number  as  having  occurred  during  the  progress  of  typhoid 
fever  and  in  acute  rheumatism.  In  the  first  of  these  diseases  the 
displacement  of  the  bone  has  occmTed  in  the  earlier  days  of  con- 
valescence, when  the  patient  has  been  so  feeble  that  it  has  seemed 
as  if  the  accident  was  due  to  the  relaxation  of  the  coverings  of  the 
joint  and  its  associated  muscles,  with  the  result  that  the  bone 
has  easily  slipped  out  of  place,  and  in  nearly  all  these  cases  there 
has  been  no  evidence  whatever  of  any  local  difficulty  prior  to 
luxation.  On  the  other  hand,  in  acute  articular  rheumatism  where 
dislocation  has  taken  place  there  has  nearly  always  been  a  history 
of  arthritic  difficulty  prior  to  the  accident,  and  instead  of  the  dis- 
location producing  pain  of  a  moderate  degree,  as  it  has  done  in 
convalescence  from  typhoid  fever,  the  occurrence  of  the  displace- 
ment has  been  followed  by  great  relief  from  pain,  owing  to  the 
overcoming  of  the  vicious  attitude  which  has  been  maintained  by 
the  limb.  The  cases  of  scarlet  fever  in  which  this  accident  has 
occurred  have  belonged  rather  to  the  typhoid  class,  in  that  the 
dislocation  has  taken  place  without  much  pain,  and,  therefore, 
without  attracting  great  attention  to  its  presence. 

As  long  ago  as  18S2  Rawden  reported,  in  the  Liverpool  Medico- 
Chirurgical  Journal,  an  instance  of  dislocation  follo\^^ng  typhoid 
fever,  in  which,  having  excised  the  head  of  the  bone,  he  found  it 

1  Robin  and  Leredde.     Archives  G<5n^rales  de  Mddecine,  September,  1894. 
^  Porter.     American  Journal  Orthopaedic  Surgery,  1904-5,  ii,  167—172. 


.lOINTH  265 

practically  iioniiiil,  even  llic  cartilji^*;  bciri^  licaMliy,  cxfcptin;.'-  \i>r 
a  little  ab.soq)tion  at  lis  [X'riplicry;  while,  on  flif  oiIkt  IkmkI, 
Adams,  in  a  case  of  rheumatic  (lislocation  of  ilic  lii|>,  I'dmikI  the 
capsular  ligament  ruptured  and  (lie  (orn  margins  f>l"  die  r«-nt 
closely  eml)racing  the  neck  of  tin;  bone. 

While  it  is  true  that  unobtrusive  monarticular  synovitis  with 
effusion  may  take  place  in  convalescent  patients,  the  literature  of 
the  subject  does  not  reveal  the  fact  that  post-typhoidal  flislocations 
have  usually  been  due  to  this  condition,  and  Collier  believes  that 
degenerative  changes  similar  to  those  seen  in  muscular  fibers  result 
in  softening  of  the  hgaments  and  of  their  attachment  (o  ihe  bones. 
The  possibility  of  recurrence  of  the  dislocation  under  such  circum- 
stances is  great,  and  the  prognosis  as  to  the  correct  use  of  the 
limb  must  be  made  with  caution,  since  some  cases  seem  to  become 
entirely  well,  while  others  never  get  rid  of  a  certain  amount  of 
ankylosis  or  shortening. 

In  this  connection  it  may  be  a  matter  of  interest  to  note  that  the 
case  of  typhoid  fever  with  knee  involvement  under  the  senior 
author's  care  in  the  wards  of  the  Jefferson  Medical  College  Hos- 
pital in  the  early  part  of  1897,  to  which  reference  is  made  in 
Keen's  essay,  page  97,  was  seen  by  the  senior  author  again  in 
March,  1899.  She  was  able  to  walk  without  the  aid  of  a  crutch,  but 
the  knee  was  permanently  ankylosed.  It  will  be  remembered  that 
aspiration  of  this  knee-joint  obtained  fluid  wliich  was  perfectly 
sterile.  A  much  more  interesting  point  in  connection  with  the 
case,  from  a  prognostic  point  of  view  for  other  cases,  is  that  the 
ankylosis  in  marked  flexion,  wdiich  Dr.  Keen  thought  would 
require  operative  treatment  later  on,  was  gradually  overcome, 
so  that  shortening  in  the  ankylosed  limb  was  very  slight. 

Prieto^  has  reported  a  case  of  artliritis  involving  the  tarsal  and 
metatarsal  bones,  and  Laignel,  Larastine,  and  de  Jong'  have  re- 
ported cases  of  osteitis  and  periostitis  after  typhoid  fever. 

1  Prieto.     Eev.  de  med.  y  Cirug.  pract.,  Madrid,  1907,  Ixxvii,  96. 

^  Laignel,  Larastine,  and  de  Jong.     Bull,  med.,  Paris,  190S,  xxii,  151. 


CHAPTER    Y. 

THE  COXDITIOXS  WHICH  RESEMBLE  TYPHOID  FEVER. 

These  conditions  are  quite  numerous.  The  following  is  a  list 
of  the  more  common  of  them:  ^Malarial  fever,  appendicitis,  sepsis, 
pneumonia  with  great  asthenia,  tuberculosis,  particularly  of  the 
abdominal  contents;  ileocolitis,  ulcerative  or  septic  endocarditis, 
scarlet  fever,  cerebrospinal  meningitis,  and  paratyphoid  infections. 

Since  the  first  edition  of  this  essay  appeared,  the  continued  use 
of  the  "Widal  test,  with  a  clearer  knowledge  of  its  limitations,  and 
the  advances  made  in  the  methods  of  studying  the  blood  by  means 
of  cultures,  particularly  by  the  simplified  method  of  Conradi- 
Drigalski,  to  determine  its  bacteriological  contents,  have  made  it 
possible  to  separate  typhoid  infection  from  the  above  conditions. 
It  is  to  be  remembered  that  although  comparatively  few  physicians 
possess  the  necessary  apparatus,  or  the  bacteriological  training, 
necessary  for  the  successful  carrying  out  these  tests,  they  have 
at  their  command  full  assistance  in  the  many  laboratories  which 
have,  because  of  the  universal  demand,  been  established  throughout 
the  country. 

With  the  important  question  of  the  diagnosis  from  malarial 
fever  we  have  already  dealt  in  the  chapter  on  the  Well-developed 
Stage  of  the  Disease.  The  important  facts  for  the  physician  to 
remember  are  that  the  infection  by  the  bacillus  of  Eberth  and  that 
bv  the  parasite  of  malarial  fever  may  pursue  a  course  in  each  case 
almost  identical  with  one  another,  and  that  in  such  cases  a  differen- 
tial diagnosis  is  to  be  made  chiefly  by  means  of  the  Widal  test  on 
the  one  hand  and  a  search  for  the  malarial  organism  on  the  other. 
It  is  also  to  be  recalled  that  the  quinine  test  is  not  of  great  nega- 
tive value,  and  that  its  persistent  use  in  a  malarial  case  may  simply 
make  the  microscopic  diagnosis  impossible.  For  these  reasons 
the  use  of  quinine  for  several  days  without  result  should  not  be 
persisted  in,  since  the  case  under  these  circumstances  is  probably 


TIU<:  CONDITIONS   WHICH   Ji/i>SJwMnJJ'J   TYl'IIOllj  FEVEii     207 

not  due  to  miliaria.  Spciikin^  of  lliis  tlicnipcutif:  test,  \)uv\.  \\c\\ 
says:  "In  a  case  reseiiibliii^  typlioid  fever,  hut  ntally  rniihuial, 
the  microscope  is  essential  to  ^ofxl  [)ractice.  Without  it,  (|uiiu'ne 
may  again  he  used;  hnl  if  Ihc  Icnipcriiliiic  iV)v<.  not  full  lo  oi-  ocar 
normal,  with  relief  to  the  other  syinj)tonis,  il  is  hcttcr  to  stop 
quinine  altogether.  Only  when  inicroscopir-  evideiife  of  malaria 
is  present  should  the  di'ug  he  piislicd  ;d'(cr  the  diiid  day.  It  is 
necessary  to  add  that  while  symptoms  persist,  the  jxitient  should 
be  treated  as  though  he  had  typhoid  fever.  So  erroneously  is  the 
so-called  therapeutic  test  conceived,  that  I  have  known  of  patients 
taking  quinine  in  doses  of  forty  grains  a  day  U)y  tliice  weeks,  in 
order  to  determine  the  presence  of  malaria,  each  fall  of  1°  or  2° 
of  temperature  being  looked  on  as  proof  of  a  s[)ecific  efi'ect.  I  am 
well  aware  that  some  look  on  massive  doses  of  fjuinine  as  useful 
in  typhoid  fever,  but  considerable  observation  has  convincwl  me 
of  the  opposite  view." 

With  these  views,  particularly  those  of  the  last  sentence,  the 
writers  are  in  entire  accord.  The  facts,  already  well  emphasized 
in  this  essay,  that  severe  chills,  rigors,  and  sweats  may  appear  in 
many  cases  of  typhoid  fever  entirely  devoid  of  any  trace  of  malaria, 
proves  that  all  these  signs  are  not  proof  of  malarial  infection.  In 
confirmation  of  these  views  we  find  the  interesting  report  of  Ewing,^ 
made  after  his  able  studies  among  soldiers  of  the  Spanish-American 
war  at  Montauk  Point,  in  which  he  says: 

"The  reason  why  the  blood  was  examined  in  159  cases  of 
typhoid  fever,  was  the  intermittent  character  of  the  fever,  wliich 
was  exhibited  in  patients  both  with  and  without  malarial  antece- 
dents. In  no  case  of  undoubted  and  established  typhoid  fever 
were  malarial  parasites  found  in  the  blood  in  connection  with  any 
of  these  sudden  rises  of  temperatm-e,  but  only  at  the  onset  of  the 
disease  or  during  the  convalescence. 

"On  the  other  hand,  many  patients  whose  blood  contained 
numerous  parasites  were  seen  in  the  'typhoid  state,'  but  there 
were  always  some  essential  symptoms  lacking  to  confirm  the  diag- 
nosis of  typhoid  fever,  wdiile  the  subsequent  course  of  the  disease 
demonstrated  the  purely  malarial  character  of  the  fever. 

1  Ewing.     New  York  Medical  Journal,  February  4,  1S99. 


268      THE  CO^DITIOXS   WlllL'II   RESEMBLE  TYPHOID  FEVER 

"These  patients  might  suffer  from  epistaxis,  ha-matemesis, 
bloody  stools,  tympanites,  a  few  rose  spots,  though  oftener  herpes, 
diarrhoea,  and  delirium,  and  in  some  a  partial  Widal  reaction  was 
obtained.  But  the  intestinal  symptoms  were  inconstant  or  refer- 
able to  dysentery  or  simple  diarrhoea,  from  which  many  of  the 
malarial  cases  suffered,  and  these  patients  never  showed  sub- 
sultus  or  cracked  tongues,  and  they  did  not  die,  or,  if  they 
did,  dysentery  and  malaria  were  demonstrated  at  or  before 
autopsy." 

Ao-ain,  he  says:  "It  is  possible  that  some  of  these  patients 
suffered  from  both  active  malaria  and  typhoid  fever,  but  there 
were  no  positive  indications  that  the  latter  infection  was  present. 
In  the  cases  that  came  to  autopsy  there  was  never  any  doubt  of 
the  natiu-e  of  the  disease.  It  was  either  typhoid  fever  or  malaria, 
but  never  both,  although  microscopic  evidence  of  dormant  mala- 
rial infection  was  found  in  at  least  two  cases  of  typhoid  fever. 

"In  short,  in  spite  of  very  painstaking  efforts,  the  attempt  to- 
find  a  case  of  typhoid  fever  and  active  malaria  progressing  simul- 
taneously was  unsuccessful." 

From  a  study  of  tliis  group  of  cases  Ewing  concluded : 

"1,  That  typhoid  fever  is  to  a  large  extent  incompatible  with 
active  malarial  fever,  and  that  during  the  course  of  the  former 
the  latter  infection  is  usually  suppressed. 

"2.  That  the  presence  of  old  malarial  infection  may  alter  the 
course  of  typhoid  fever  through  the  anaemia,  but  that  active  sporu- 
lation  of  the  malarial  parasite  very  rarely  occurs  during  the  course 
of  established  typhoid  fever. 

"3.  On  the  other  hand,  since  malarial  paroxysms  often  reappear 
during  convalescence,  a  scanty  growth  of  the  parasite  must  often 
persist  during  the  course  of  typhoid  fever,  and  it  is  possible  that 
some  of  the  irregularities  of  temperature  observed  in  these  cases- 
are  referable  to  this  partly  suppressed  growth. 

"4.  That  the  anatomical  evidence  of  a  postmortem  examination 
is  much  needed  to  demonstrate  the  existence  of  typhoid  fever  in 
cases  showing  active  malarial  paroxysms." 

A  valuable  paper  upon  the  relations  of  typhoid  fever  to  mala- 
rial infection  was  published  some  years  ago  by  Oilman  Thomp- 


riii<:  CONDITIONS  wiiK'ii  i{.h:si':MiiLi':  tvi'iioii)  i<'i-:vi-:it    200 

soil,'  ill  wliicli  lie  I'cjiclicd  rcsiills  i(|('iilic;il  willi  tlioic  jii  t  liilc'l, 
namely,  that  the  fever  of  ty})h(>i(l  is  iipt  to  run  its  course,  and 
that  malarial  manifestations  then  sij(:c;c(,"(i  il. 

It  is  of  interest  to  note  that  although  many  (;f  (he  jj;i(ients  siifff-r- 
ing  from  typhoid  fever  at  the  Johns  Hopkins  Hospital  eonif  from 
malarious  regions,  only  three  cases  of  simultaneous  infef;tion  by  tlie 
malarial  parasite  and  the  Bacillus  typhosus  are  known  to  have 
occurred  in  1100  cases  of  typhoid  fever  admitted  to  that  institution. 
Lyon,  who  reported  one  of  these,  was  able  to  collect  from  the  litera- 
ture only  29  undoubted  cases,  but  there  were  many  others  in  which, 
although  the  evidence  was  not  so  conclusive,  it  seemed  jjrobable 
that  a  mixed  infection  did  exist,  and  he  concludes  that  in  tr(;[;ical 
countries,  where  malarial  fever  is  endemic  and  typhoid  fever  prev- 
alent, combined  infections  are  probably  common. 

As  already  stated,  since  the  more  prevalent  use  of  the  Ijlood 
culture  and  the  Widal  test,  on  the  one  hand,  and  a  more  careful 
search  for  the  malarial  parasite  in  the  stained  blood  smear  on  the 
other,  the  differential  diagnosis  of  the  two  conditions  has  been 
rendered  less  difficult,  and  physicians  are  reaching  the  conclusion 
expressed  by  Dr.  Osier  some  years  ago,  that  "there  is  no  such 
entity  as  typhomalarial  fever,  there  being  but  two  forms  of  con- 
tinued fevers  in  the  South,  the  one  due  to  typhoid,  the  other  due 
to  malarial  infection." 

Pysemic  and  septicsemic  affections,  such  as  infective  endocarditis, 
osteomyelitis,  puerperal  septicaemia,  and  even  appendicitis,  or 
otitis  media,  may  somewhat  closely  resemble  typhoid  fever  if  these 
affections  are  insidious  and  there  is  pus  present  which  produces  a 
toxaemia.  Whatever  the  cause  of  the  sepsis  may  be,  the  loss  of  flesh, 
dry  tongue,  delirium,  low^-grade  broncliitis,  badly  nourished  skin, 
and  diarrhoea  may  cause  the  patient  to  be  most  t}^hoid  in  appear- 
ance, yet  in  all  such  cases  we  should  seek  for  a  possible  purulent 
focus.  The  absence  of  a  positive  cultm-e  or  of  the  Widal  reacdon  and 
the  presence  of  leul<:ocytosis  should  arouse  om-  suspicions  greatly,  and 
it  is  not  to  be  forgotten  that  the  presence  of  pus  deep  in  the  pehis 
or  in  the  neighborhood  of  the  kidney  may  not  be  readily  discovered, 
so  that  only  the  development  of  fluctuation,  or  the  rupture  of  the 

1  Thompson.     American  Journal  of  the  Medical  Sciences,  August,  1894. 


270      THE  COXDITIOXS   WHICH   RESEMBLE  TYPHOID  FEVER 

abscess,  will  force  the  physician  to  revise  his  diagnosis  of  typhoid 
fever.  On  the  other  hand,  as  already  pointed  out,  piu'ulent  forma- 
tions may  occur  in  typhoid  fever,  the  Bacillus  typhosus  acting  as  a 
pyogenic  organism,  or  the  sepsis  may  be  due  to  associated  infection 
by  other  organisms. 

Similar  symptoms  make  us  suspect  and  search  for  signs  and 
causes  of  ulcerative  endocarditis  in  such  cases. 

The  fact  that  tuberculosis  may  simulate  typhoid  fever,  and  that 
cerebrospinal  meningitis  may  likewise  do  so,  has  already  been  dis- 
cussed in  the  foregoing  pages,  but  it  is  not  out  of  place  to  point 
out  that  four  types  of  tuberculosis  are  particularly  apt  to  produce 
misleading  symptoms.  In  tuberculous  meningitis  the  febrile  move- 
ment is  rarely  as  high  as  in  typhoid  fever  with  associated  meningeal 
symptoms;  the  abdomen  is  usually  scaphoid  instead  of  tympanitic, 
and  the  persistent  vomiting  of  the  former  disease  is  comparatively 
rarely  met  with  in  the  latter.  An  ocular  examination  may  reveal 
optic  neuritis  in  tuberculous  meningitis,  or  paralysis  of  the  muscles 
of  the  eyeball,  causing  squint. 

An  aid  never  to  be  forgotten  in  these  cases  is  afforded  by  a  careful 
examination  of  the  cerebrospinal  fluid  removed  by  limibar  puncture, 
which  will  many  times  reveal  the  presence  of  tubercle  bacilli  or  an 
excess  of  lymphocytes.  An  additional  aid  in  diagnosis  is  a  careful 
and  persistent  examination  of  the  urine  and  faeces,  which  may 
reveal  tubercle  bacilli,  when  an  examination  of  the  sputum  is 
negative. 

It  is  also  to  be  remembered  that  even  in  patients  who  have 
fever  much  may  be  learned  by  the  use  of  the  cutaneous  tuberculin 
test,  which  is  entirely  without  danger  if  the  necessary  precautions 
are  used  in  performing  it. 

So,  too,  in  acute  general  miliary  tuberculosis,  the  previous  his- 
tory of  the  patient  as  to  gradual  failure  of  health,  and  cough,  and 
the  rigors  and  sweats  point  to  the  presence  of  tuberculosis  rather 
than  enteric  fever.  Further,  there  AAdll  be  in  some  cases  marked 
physical  signs  of  widespread  involvement  of  the  lungs  in  tubercu- 
losis which  will  be  absent  in  typhoid  fever.  It  is  to  be  recalled, 
however,  that  a  roseolar  rash  may  develop  in  both  affections,  and 
that  diarrhoea  and  a  dry,  brown,  tongue  may  mislead  the  careless 


rJlE  CONDITION!^   WfffCff   R/CSKMBfJ-:  TYI'llOlh   I'KVEU      271 

very  readily.  Mvcn  itilc.s(in;il  liciii'>rrli;ii^';('  rii;i\'  ocrin'  in  iiiili;iry 
tul)er('iil()si,s.' 

Tubercul(Mi,s  jK-ritc^iiiU.s  may  also  cau.sf;  tvplioid  syniptf^ins,  l>ijt 
as  the  disease  progresses  the  locahzation  of  tlic  a}>dorr)inal  syrn[>- 
toms  and,  finally,  the  development  of  tumor  masses  or  enlarge- 
ment of  the  mesenteric  glands,  can  he  felt  on  deep  palpation, 
or,  in  other  cases,  the  development  of  ascites  makes  the  diagnosis 
clear. 

Girandau^  has  recorded  a  case  in  which  a  young  man  sufffTcd 
from  enteric  fever,  and  then  speedily  develope<l  tuberculous 
disease  of  the  intestines.  Two  weeks  after  the  recovery  from 
enteric  fever  the  patient  became  ill  a  second  time,  with  diarrhoea, 
fever,  and  abdominal  pain,  and  marked  wasting.  At  the  autopsy 
two  sets  of  lesions  were  found,  typhoid  lesions  side  by  side  with 
tuberculous  foci.  No  traces  of  old  pulmonary  lesions  or  a  primary 
lesion  elsewhere  were  to  be  found. 

Finally,  it  is  to  be  recalled  that  that  rather  rare  disease,  gen- 
eral miliary  tuberculosis,  may  make  the  diagnosis  obscure.  Some 
time  since  one  of  us  (Hare)  saw  in  consultation  a  man,  aged  thirty 
years,  who  had  had  for  four  weeks  persistent  fever,  some  cough, 
diarrhoea,  mild  delirium,  gradual  loss  of  flesh,  and  a  heavily  coated 
tongue,  with  sordes.  To  the  mind  of  attending  physician,  who  had 
made  a  diagnosis  of  enteric  fever  at  the  start,  nothing  had  occm-red 
to  make  liim  change  his  views,  but  the  appearance  of  the  patient 
made  me  suspicious  of  tuberculosis,  and  a  careful  examination  of 
his  chest  revealed  well-advanced  tuberculosis  of  the  lungs,  the 
real  cause  of  his  illness. 

An  interesting  case  illustrating  how  difficult  the  diagnosis  of 
typhoid  fever  may  be  in  its  earlier  stages  has  recently  been  under 
the  care  of  the  senior  author: 

This  woman  was  taken  ill  some  days  before  one  of  us  (Hare)  saw 
her  with  cliilliness,  fever,  and  languor,  and  with  a  further  liistory 
that  she  had  been  suffering  for  a  number  of  months  with  somewhat 
similar  sensations  without  the  fever,  and  had  been  losing  flesh. 
Diu'ing  this  time  she  had  had  constipation  alternating  with  diarrhoea 

1  Senator.     Charity  -AjiDalen,  1892,  xvii,  272. 
-  Girandau.     Revue  de  Medecine,  1884,  p.  564. 


272      THE  COXDITIOXS   WIIJCJJ    nKF^FMBI.E   TYPHOID  FEVER 

and  abdominal  pain.  When  first  seen  her  temperature  was  103°; 
her  appearance  was  distincdy  that  of  a  typhoid  patient;  but,  as  is 
seen  in  the  accompanying  chart  (Fig.  2G),  her  temperature  speetHly 
fell  to  normal,  only  one  sponge  bath  being  required  after  she  came 
under  observation.  An  examination  of  her  abdomen  at  this  time  re- 
vealed the  fact  that  it  was  slightly  protruding,  and  that  the  abdom- 
inal wall  was  so  thin  that  the  coils  of  intestine  could  be  readily  seen 
projecting  through  it.  In  the  neighborhood  of  the  umbilicus  there 
was  a  sense  of  increased  tenderness  on  deep  palpation,  and  the  re- 

FiG.  26 


A  case  of  tjTihoid  fever  preceded  by  appendicitis  (?),  or  by  a  primary  attack  of  typhoid 

fever. 

sistance  made  one  suspect  the  possibility  of  there  being  present  a 
tuberculous  peritonitis  which  had  caused  an  exudation,  binding  the 
intestines  together  in  a  mass.  About  McBurney's  point  there  was 
very  distinct  tenderness  on  palpation,  and  deep  palpation  produced 
severe  pain.  In  view  of  her  history,  her  emaciation,  and  the  symp- 
toms detailed,  we  were  inclined  to  consider  the  case  one  of  tubercul- 
lous  peritonitis,  or  else  one  of  appendicitis  of  the  subacute  or  chronic 
character,  with  a  tendency  to  exacerbations.  In  this  opinion  Pro- 
fessor Keen  agreed  with  us,  and  it  was  arranged  that  Professor 
Keen  should  perform  an  abdominal  section  for  the  purpose  of 
removing  the  appendix,  if  it  alone  was  the  cause  of  the  difficulty. 


TIIFj   ('ONI)ITIONH   which  RESEMBLh'  TV  I' HOI  b  FKVEU     27.'{ 

or  of  fclicviiiii^'  licr  ( iihcrciiloiis  pcfilonitis  (liroiiii^li  tli(;  wdl-knowti 
beneficial  effects  of  abdominal  .section.  On  the  day  on  wiiich  .she 
was  to  be  operated  upon,  her  temperature  having  Ix-nn  normal 
for  a  number  of  days,  and  her  general  condition  having  stcjidily 
improved  under  treatment  designed  to  pref>are  her  .system  for 
operation,  slie  (lovelo})ed  marked  lano;uor  and  malaise  and  fcijrile 
movement,  which  is  shown  in  the  accompanying  chart  (Fig.  20;, 
and  three  days  later  developed  typical  rose  rash  of  typhoid  fever, 
her  blood  giving  the  positive  Widal  reaction  .simultaneou.sly.  I'he 
questions  which  naturally  ari.se  in  regard  to  this  case  are:  l-)id 
the  woman  suffer  primarily  from  appendicitis,  or  from  tuberculous 
peritonitis,  or  did  she  come  under  my  care  at  the  end  of  a  mild 
primary  attack  of  typhoid  fever  after  which  she  harl  a  relapse,  or, 
again,  is  it  possible  that  suffering  from  a  mild  chronic  intestinal 
catarrh,  she  received  typhoid  infection  just  prior  to  her  entering 
the  ward,  thereby  superimposing  typhoid  fever  upon  the  condi- 
tion present  when  we  first' saw  her?  Because  of  her  ultimate 
complete  recovery  we  are  inclined  to  believe  that  the  primary  fever 
could  not  have  been  due  to  tuberculous  peritonitis. 

Another  interesting  case,  illustrating  how  difficult  these  differ- 
ential diagnoses  may  be,  is  reported  by  Dresclifeld  in  AUbutt's 
System  of  Medicine,  in  which  three  members  of  one  family  that 
had  lived  in  a  cellar  which  had  been  under  water  at  the  time  of 
an  extensive  flood  were  attacked  T\-ith  a  fever.  Their  symptoms 
closely  resembled  those  of  enteric  fever,  and  one  of  them  pre- 
sented on  the  tliird  day  after  admission  marked  roseolar  spots,  and 
had  slight  intestinal  hemorrhage  on  the  fifth  day.  The  tempera- 
ture showed  marked  exacerbations,  and  the  patient  died  from 
exhaustion  on  the  foiu-teenth  day  after  admission,  or  about  the 
seventeenth  day  of  the  fever.  The  postmortem  examination 
revealed  the  intestines  apparently  healthy.  Dresclifeld  says  he 
can  quote  similar  cases.  He  does  not  state  what  he  believed  this 
illness  to  be  due  to,  but  from  the  context  he  evidently  regarded 
it  as  septic,  although  the  absence  of  intestinal  lesions,  as  we  have 
already  stated,  does  not  exclude  enteric  fever. 

Leu^  has  reported  a  case  of  puerperal  septicaemia  which  was 

1  Leu.     Charity  Annalen,  1891,  srv-i,  315. 
18 


274      THE  COXDITIOXS   WHICH  RFSEMBLE    TYPHOID  FEVER 

almost  indistino^uishabk'  from  tyj^hoid  fever,  for  the  patient  had  a 
rose  rash,  tympanites,  enhirged  spleen,  intestinal  infection,  and  the 
pyrexial  cm-ve,  which  is  characteristic.  The  fact  that  puerperal 
septicaemia  is  fatal  within  a  few  days,  that  there  is  a  local  focus 
of  the  disease,  and  that  such  a  disease  would  not  present  the  AYidal 
reaction  nor  give  blood  cultures  of  typhoid  bacillus,  would  aid  us 
in  making;  a  differential  diay-nosis. 

Another  condition  which  may  closely  simulate  enteric  fever  is 
the  g'astro-intestinal  form  of  epidemic  influenza,  for  in  this  con- 
dition we  have  enlargement  of  the  spleen,  diarrhoea,  tympanites, 
gurgling,  slight  evidences  of  bronchial  irritation,  and  very  rarely, 
indeed,  a  suspicious  roseolar  rash.  It  is  perfectly  possible  for 
enteric  fever  and  influenza  to  occur  simultaneously  in  the  same 
patient. 

Under  the  name  of  mounfain  fever,  a  febrile  disease  occurring 
in  the  great  highlands  which  occupy  the  middle  portion  of  the 
United  States  has  been  described  by  a  number  of  authors.  Some 
of  these  "VM'iters  have  been  strongly  of  the  opinion  that  mountain 
fever  is  a  distinct  entity,  while  others  have  gone  so  far  as  to  assert 
that  it  is  an  irregular  manifestation  of  malarial  poisoning,  and 
still  others  that  it  is  a  modified  form  of  typhoid  fever. 

As  a  matter  of  fact,  we  may  state  positively  at  this  time  that 
true  "mountain  fever"  is  in  all  cases  nothing  more  than  a  greatly 
modified  or  altered  type  of  typhoid  infection.  As  has  already 
been  pointed  out  in  this  essay  a  number  of  times,  typhoid  fever 
is  a  disease  which  varies  greatly  in  its  symptomatology  and  course, 
and  does  not,  in  many  instances,  follow  the  classical  descriptions 
of  it  which  we  are  accustomed  to  find  in  the  text-books. 

One  of  the  most  conclusive  and  interesting  papers  dealing  with 
this  matter  which  is  to  be  found  in  recent  literature,  is  that  of 
Raymond,  who,  as  post  sm'geon  at  one  of  the  United  States  Army 
stations  in  the  West,  has  contributed  to  the  American  Journal  of 
the  Medical  Sciences,  1898,  vol.  cxv,  an  exhaustive  paper  upon  this 
subject,  while  Woodruff,^  also  of  the  Army  Staff,  has  reported 
thirty-five  cases  at  Fort  Custer,  which  he  says  w^ould  certainly 
have  been  described  as  mountain  fever,  but  in  which  the  clinical 

'  Woodruff.     Jour.  Amer.  Med.  Assoc,  1898,  xxx,  753. 


THE  CONDITIONS  WHICH  /^'Hs/'.uii/j-:  TYi'iioii)  i<i:vi:ii    27.O 

i'eiitiircs  and  tlio  VVidiil  rcuclioii  .sIkavc!*!  lliaL  lli(;rc  was  no  question 
of  the  disease  being  other  that  typhoicJ. 

Quinine  administered  lo  (liese  cases  in  full  doses  failed  to 
exercise  any  beneficial  ('fleet;  prophyhictir;  measures,  which  are 
ordinarily  successful  in  the  control  of  the  lyplioid  cfjidernic,  at  once 
checked  the  disease,  and  a  couipnrison  of  in;iny  of  the  symptoms 
manifested  with  those  met  with  in  irregular  forms  of  typhoid 
fever  still  further  indorse  the  view  we  have  already  expressed  in 
regard  to  the  unity  of  these  two  diseases. 

These  views  in  regard  to  mountain  fever  are  also  supported  by 
the  paper  of  Work,^  who  tells  us  that  IS  out  of  50  cases  of 
mountain  fever,  so  called,  had  rose  spots,  and  that  in  5  fatal 
cases  the  intestinal  lesions  of  the  fever  were  found. 

By  the  term  "mountain  fever"  we  do  not,  of  course,  refer  to 
the  "tick  fever"  of  Montana. 

The  differential  diagnosis  of  typhoid  fever  in  children  from  the 
other  exanthemata  is  made  as  follows :  From  scarlet  fever,  by  the 
sudden  onset  with  vomiting,  by  the  presence  of  sore  throat,  the 
characteristic  tongue,  the  excited  nervous  system,  and  the  early 
appearance  of  the  scarlet  rash.  From  measles,  by  the  presence  of 
Koplik's  spots,  by  the  coryza,  wliich  is  rare  in  typhoid  fever,  the 
marked  bronchial  catarrh,  and  the  early  characteristic  rash.  From 
enterocolitis  we  distinguish  enteric  fever  by  the  absence  of  delirium 
or  stupor  in  the  former  affection,  and  the  character  of  the  diar- 
rhoea, as  well  as  the  greater  abdominal  tenderness. 

The  value  of  the  blood  culture  as  well  as  of  the  AVidal  reaction  is 
never  to  be  forgotten  in  connection  with  these  questionable  cases. 

1  Work.     Medical  News,  April  S,  1894. 


CHAPTER    VI. 

DURATION  AND  IMMUNITY  TO  SECOND  ATTACKS. 

Duration, — The  duration  of  typhoid  fever  varies  greatly  in 
different  individuals,  and  still  more  so  in  different  epidemics, 
depending  upon  the  vital  resistance  of  the  patient  and  the  virulency 
of  the  infection.  It  mav,  however,  be  asserted  that  the  average 
period  of  fever  is  twenty-one  days,  although  mde  variations  from 
this  may  occur,  the  dm'ation  being  much  less  or  much  greater,  as 
already  pointed  out. 

IMurchison  states  the  mean  duration  in  seventy-five  cases  to 
be  a  fraction  more  than  twenty-four  days.  Flint  states  from 
going  to  bed  to  normal  temperature  sixteen  days,  A\dth  a  maximum 
of  twenty-eight  days  and  a  minimum  of  five  days.  The  longest 
case  seen  by  Flint  was  of  fifty-eight  days'  duration,  while  Musser^ 
reports  one  in  which,  though  there  were  no  known  complications, 
the  temperature  did  not  reach  normal  until  seventy-three  days 
had  elapsed.  Tliis  last  case  probably  illustrates  an  associated 
bacteremia. 

Paul  Claisse"  reports  a  case  that  had  two  hundred  days  of  fever. 
In  this  case  the  initial  fever  was  followed  by  five  relapses. 

Of  45  of  Flint's  fatal  cases  the  duration  was  a  fraction  more 
than  fourteen  days.  Murchison  tells  us  that  the  mean  stay  in 
the  hospital  of  500  cases  which  recovered  was  31.24  days;  of 
100  fatal  cases,  16.52  days;  while  the  average  duration  of  illness 
before  admission  of  the  600  cases  was  10.78  days.  Again,  Mur- 
chison tells  us  that  the  pyrexia,  as  a  rule,  lasts  at  least  three 
wrecks,  and  the  ordinary  duration  of  enteric  fever  is  from  three  to 
four  wrecks.  Of  200  cases  which  recovered,  and  in  which  he  was 
able  to  fLx  the  commencement  with  tolerable  certainty,  the  dura- 

1  Musser.     Proceedings  of  the  Pathological  Society,  May,  1899. 
*  Claisse.     La  Presse  M^dicale,  June  6,  1906. 


DURATION  AND  IMMUNITY  TO  SECOND  ATTACKS      277 

tion  was  ten  to  fourteen  days  in  7  cases;  fifteen  to  twenty-one 
clays  in  41)  cases;  two  to  tw(!nty-eif^ht  days  in  1  I  1  ca.ses;  twenty- 
nine  to  thirty-five  days  in  'A'.i  cases. 

The  mean  (hn-ation  of  the  200  cases  was  24. 'i  days,  sind  the 
mean  duration  of  112  otfier  cases,  wfiicfi  were  fatal,  was  27.07  days. 

The  average  duration  of  residence  in  St.  Thomas'  Hospital, 
London,  in  1.S94,  1895,  and  1890,  was  from  43.1  to  51.8  day.s, 
and  the  average  duration  of  fever  from  14.3  to  10.73  days,  but 
a  great  proportion  of  the  patients  were  achnitted  in  the  first  or 
second  week  of  the  malady. 

In  the  Maidstone'  epidemic,  8  per  cent,  lasted  two  weeks;  27 
per  cent.,  three  weeks;  31  per  cent.,  four  weeks;  17  per  cent., 
five  weeks;  8  per  cent.,  six  weeks;  4.5  per  cent.,  seven  weeks; 
8.4  per  cent.,  eight  weeks. 

If  we  take  the  25  cases  admitted  in  the  first  week  of  the  dis- 
ease given  in  Wilson's  table,^  we  find  that  the  average  stay  of 
these  patients  in  the  house  was  forty-one  days  (40-|),  and  the 
average  day  of  normal  temperature  the  nineteenth.  The  average 
maximum  temperature  was  104.6°.  If  the  entire  108  cases  given 
in  his  last  table  in  liis  article  are  studied,  we  find  that  the  average 
duration  of  the  fever  was  in  the  cases  admitted  in  the  second  week, 
23.2  days;  in  the  third  week,  27.3  days,  and  the  average  stay  in  the 
house  of  the  second  week  cases,  40.8  days,  and  of  the  tliird-week 
cases,  38.8  days. 

While  the  general  average  may  be  about  twenty-one  days,  very 
much  shorter  periods  have  been  seen  and  noted  by  every  physician 
of  experience,  and  very  important  classifications  of  cases  have 
been  made  by  Liebermeister  and  Jurgensen.  The  first  of  these 
clinicians  speaks  of  the  mildest  cases  as  those  in  wliich  the  rectal 
temperature  never  or  rarely  rises  above  103°,  and  the  duration  of 
fever  does  not  exceed  eight  days.  The  mild  cases  do  not  have  a 
rectal  temperature  above  104.8°,  and  the  fever  lasts  sixteen  days. 
The  severe  cases  are  those  in  wliich  the  rectal  temperature  rises 
above  105°,  and  the  fever  ceases  by  the  twenty-first  day.  .Jm-- 
gensen  considers  all  cases  mild  which  have  no  fever  after  the 

1  Poole.     Guy's  Hospital  Reports.  189S.     (Wrongly  labelled  on  cover,  1S96.) 
-  American  System  of  Therapeutics. 


278      DURATIOX  AXD  IMMl'XITY  TO  SECOXD  ATTACKS 

tenth  day,  and  those  severe  that  have  fever  after  this  date;  but 
this  view  hardly  coincides  with  that  of  American  physicians,  who 
regard  an  infection  ending  by  the  twenty-first  day  as  quite  moderate, 
particuhirly  if  the  fever  does  not  exceed  104°.  Of  late  there  have 
been  jjublished  reports  of  cases  with  positive  blood  cultures  for 
typhoid  bacilli  in  which  the  fever  was  of  very  short  duration, 
although  giving  the  typical  signs  and  symptoms  of  the  disease. 
Sir  Dyce  Duckworth^  reports  such  a  case,  while  Parkinson^  cites 
three  instances  in  which  the  fever  was  of  very  short  diu'ation  and 
one  case  wliich  ended  fatally  on  the  sixth  day,  having  had  no  fever 
after  the  second  day.  At  autopsy  it  was  found  that  the  ulceration 
had  progressed  quite  as  rapidly  with  the  temperature  normal  as  in 
ordinary  cases.  The  question  naturally  arises  in  cases  such  as 
these  as  to  whether  the  disease  has  not  existed  for  a  longer  time  than 
the  patient  or  his  physician  believes.  There  is  nothing  more  diffi- 
cult than  the  determination  of  the  actual  first  day  of  illness. 

There  is  one  class  of  patients  in  which  the  febrile  movement 
very  commonly  lasts  but  a  week  or  two,  namely,  children.  Henoch 
stated  years  ago  that  out  of  80  cases  seen  by  him  there  were  11 
which  lasted  seven  to  ten  days,  26  from  ten  to  fifteen  days,  16 
from  fifteen  to  twenty  days,  21  from  twenty  to  thirty  days,  and 
6  from  thirty  to  forty-nine  days.  Even  in  the  cases  lasting  but  a 
week  or  ten  days  there  were  roseola,  enlargement  of  the  spleen, 
and  diarrhoea.  In  confirmation  of  this  view,  we  have  the  more 
recent  observations  of  Forchheimer,  of  Cincinnati,  who  found  in 
an  epidemic  of  this  malady  among  children  that  the  fever  may 
terminate  as  early  as  the  sixth  day,  and  Janeway,  of  New  York, 
remarks  that  it  may  end  in  ten  days.  It  is  evident,  therefore,  that 
the  diu*ation  of  typhoid  fever  in  children  is  shorter  than  in  adults, 
as  a  rule,  as  well  as  milder  in  the  character  of  its  manifestations, 
and  that  it  is  accompanied  by  less  grave  intestinal  lesions. 

In  children  convalescence  is  often  more  prolonged  than  it  is  in 
adults  in  some  cases.  As  long  ago  as  1839,  Taupin^  emphasized 
this  fact,  stating  that  pallor,  feebleness,  and  general  debility  are 
marked. 

1  Duckworth.     Lancet,  January  18,  1902. 

-  Parkinson.     British  Medical  Journal,  May  2,  1901. 

'  Taupin.     Journal  des  Connais-sance  Mdd.  Cliirurgicale,  July,  18.39. 


DURATION  AND  IMMUNITY   TO  SECOND  ATTACKS      279 

Second  Attacks.  -Tlic  (|ii('.s(Ioti  f^f  tlic  frcfjuorify  of  .sofond 
attacks  of  lyj>lioi(l  fcvci-  is  of  inlci-csf.  If,  is  ^fciifr.'iily  fonsifh-rfd 
that  one  attack  renders  a  j)alieiil,  al  least  pailially  iiiiiiiiiiir-  \i)  oilier 
attacks,  but  for  many  years  there  liave  Ixcn  duriieroiis  reports 
of  second  attacks  of  the  disease.  '^J'lie  aedial  oecurrenef;  of  these 
attacks,  however, have  rarely  })een  proved  hy  positive  blood  cultures, 
\t  is  impossible,  however,  to  make  tlie  arbitrary  statement  that  no 
second  or  third  attacks  of  ty])li()id  I'ever  oeeiir.  As  in  other  infectious 
diseases,  second  and  even  tiiird  attacks  sometimes  do  occur.  These 
repeated  attacks  probably  occur  in  patients  having  an  unusual 
susceptibility  to  the  infection,  or  because  the  immunity  developed 
by  one  attack  is  lost  much  earlier  than  by  most  individuals.  Every 
physician  of  large  experience  has  seen  a  number  of  cases  which 
are  said  to  have  had  more  than  one  attack  of  typhoid  fever.  In 
a  number  of  these  cases  one  of  the  supposed  attacks  is  likely 
to  have  been  due  to  an  infection  with  the  paratyphoid  bacillus, 
the  malarial  organism,  influenza,  or  to  some  form  of  bacteremia 
developing  mthout  a  discovered  point  of  entrance,  or,  lastly,  from  an 
infection  by  the  tubercle  bacillus  which  the  vitality  of  the  patient 
has  speedily  overcome.  In  addition  to  a  careful  study  as  to  the 
possibility  of  the  disease  having  been  other  than  typhoid  fever,  it 
is  essential,  for  a  scientifically  accurate  diagnosis,  that  the  typhoid 
bacillus  be  recovered  from  the  patient's  blood,  as  the  significance 
of  the  reaction  by  the  Widal  test  is  impaired  by  the  fact  that  the 
serum  reaction  may  persist  for  months  or  even  years  following  the 
primary  attack  of  typhoid  fever. 

Coville,^  in  reporting  1400  cases  of  typhoid  fever  in  the  epidemic 
at  Ithaca,  calls  attention  to  the  fact  that  many  who  had  previously 
been  infected  again  contracted  the  disease,  but  in  a  very  mild  form. 
Recurrences  of  typhoid  fever  usually  take  place  during  epidemics, 
and  seem  more  frequent  among  men  than  women.  The  second 
attack  is  usually  milder  than  the  first,  although  this  is  not  always 
true;  ambulatory  and  exceedingly  mild  cases  make  up  a  large 
number  of  the  second  attacks,  and  the  cases  may  be  so  mild  and  the 
symptoms  so  few  and  vague  that  a  diagnosis  is  diflScult. 

'  Coville.     American  Medicine,  June  9,  1904. 


2S0      DURATIOX  AXD  IMMUXITY   TO  SECOXD  ATTACKS 

^Nloore^  lias  recordetl  a  case  of  a  man  who  suffered  from  typhoid 
fever  at  fifteen  years  and  again  at  twenty-nine  years,  and  finally 
from  a  relapse  after  this  second  attack,  and  Leidy-  has  reportetl  a 
case  of  a  boy  who  had  an  attack  of  enteric  fever  at  sixteen  years, 
a  second  attack  six  months  later,  a  third  at  the  age  of  thirty-four 
years,  and  this  followed  by  four  relapses,  in  the  third  of  wliich  he 
hatl  intestinal  hemorrhage,  but  recovery,  nevertheless,  occurred. 
Diu-ing  the  winter  of  1897-98  the  senior  author  had  under  his 
care  a  boy  who  was  suffering  from  his  third  attack  of  typhoid  fever, 
his  first  having  occurred  at  nine  years  of  age,  the  second  at  seven- 
teen years,  and  the  third  at  nineteen  years.  Death  occurred  from 
hemorrhage  of  the  bowels.  In  none  of  these  cases,  however,  was 
the  diagnosis  confirmed  bv  blood  cultures. 

Perochatid^  reported  a  case  which  appeared  authentic  in  which 
one  of  his  patients  died  during  his  third  severe  attack  of  typhoid 
fever. 

In  1626  cases  Bey  found  only  one  which  had  a  second  attack. 
One  of  us  (Beardsley)  saw  in  consultation  with.  Dr.  B.  F. 
Royer,  of  the  ^Municipal  Hospital,  a  patient  supposedly  suffering 
his  third  attack  of  typhoid  fever.  The  patient  was  a  young  physi- 
cian, who  gave  a  history  of  having,  during  a  boarding  school 
epidemic,  suffered  a  mild  attack  of  typhoid  fever  at  the  age  of 
fourteen.  At  twenty-two  years  he  suffered  a  very  severe  attack 
complicated  by  profuse  hemorhages  from  the  Ijowel,  and  during 
convalescence  from  a  persistent  neuritis  as  well  as  troublesome  bed- 
sores. The  third  attack  occurred  in  1907  and  in  the  patient's 
thirty-second  year,  and  was  typical  as  to  signs  and  symptoms,  but 
was  milder  than  either  of  the  previous  attacks.  One  week  after  the 
patient  was  out  of  bed  following  this  third  attack  of  fever,  he 
suffered  from  a  localized  pain  along  the  course  of  the  saphenous 
vein,  which  lasted  but  a  day,  but  was  suggestive  of  a  mild  phlebitis. 
During  the  last  attack  the  Widal  reaction  was  constantly  negative 
and  so  remained  during  convalescence,  and  it  is  only  fair  to  state 
that  neither  of  the  previous  attacks  was  proved  to  be  typhoid  by 

1  Moore.     Dublin  Journal  of  Medical  Science,  April,  1893. 

2  Leidy.     International  Medical  Magazine,  August,  1893. 

3  Perochaud.     Gaz.  M(5dical  de  Nantes,  July  22,  1899. 


DURATION  AND  IMMUNITY   TO  ShCON/J  ATTACKS      2S1 

the  positive  l)l()Of]  ciiltiire  or  l)y  positive  VVidjil  reii/tion,  hnl  I'lom 
a  clinical  standpoint  tlie  patient  undoubtedly  siiflVicd  lioni  duce 
distinct  attacks  of  typhoid  fever.  We  may  add  dmi  diuiiif,'  the 
last  attack  the  agglutination  reaction  vvidi  (he  paratyphoid  l);i'ilhis 
was  tried  and  was  negative. 

Although  there  can  he  no  <loid)l,  that  a  second,  and,  even  in 
extremely  rare  cases,  a  third  attack  of  typhoid  fever  may  take  place, 
we  are,  nevertheless,  convinced  that  one  altark  almost  invariably 
prevents  a  second. 


CHAPTER    YII. 

THE  IMENTAL  COMPLICATIONS.^ 

The  mental  complications  of  typhoid  fever  resemble  in  a  general 
way  the  mental  disorders  resulting  from  other  infectious  diseases. 
They  occur  by  preference  in  patients  in  whom  there  is  present  a 
neurotic  heredity  or  who  have  been  subjected,  previous  to  infec- 
tion, to  overwork,  loss  of  sleep,  anxiety,  or  other  exhausting  nervous 
strains.  Hereditary  factors — functional  neuroses  and  insanities — 
appear  to  be  present  in  about  half  the  cases.  It  cannot  be  claimed, 
however,  that  the  other  predisposing  causes  possess  much  etio- 
logical value,  as  mental  complications  frequently  occur  in  individ- 
uals in  whom  these  factors  have  been  absent.  Sex  appears  not 
to  exercise  any  predisposing  influence,  males  and  females  being 
affected  in  about  equal  number.  From  Siemerling's^  studies, 
taking  the  infection  psychoses  as  a  group,  it  would  appear  that 
females  predominate,  and  possibly  this  is  true  also  of  the  special 
instance  of  typhoid  fever.  However,  EdsalF  in  his  studies  on 
typhoidal  insanities  in  cliildhood,  found  39  cases  in  boys  and  25 
cases  in  girls.  Age,  also,  is  not  a  determining  factor.  It  is, 
however,  somewhat  significant  that  typhoid  fever  attacks  by  pref- 
erence individuals  of  an  age  at  which  mental  disorders  are  very 
prone  to  occur,  namely,  youth  and  early  adult  life.  Notwithstand- 
ing, mental  diseases  of  typhoid  origin  of  sufficient  severity  to 
demand  asylum  treatment  do  not  appear  to  be  as  frec|uent  as  this 
coincidence  would  suggest.  Thus,  Nasse  reported  43  cases  among 
2000  hospital  admissions;  Schlager,  22  cases  in  500;  Christian, 
11  in  2000;  while  Pilgrim  found  only  13  cases  in  over  6000  admis- 
sions.    Siemerling,^  who  notes  the  occurrence  of  psychoses  in  con- 

'  Bj'  Francis   X.    Dercum,  M.D.,   Professor  of  Mental   and   Nervous  Diseases  in   the 
Jefferson  Medical  College. 

-  Siemerling.     Alleg.  Zeitschr.  f.  Psychiatrie,  1904,  Band  xi,  p.  18.5. 

'  Edsall.     American  Journal  of  the  Medical  Sciences,  February,  1905,  No.  395,  p.  327. 

''  Loc.  cit. 


Till']  MENTAL  COMl'LICA'l  lONH  283 

nection  with  typhoid  fever,  artifiilnr  ili(iiiii;i(i-;iii,  ;iii'l  influfuza, 
found  amon^  ]2.'38  insane  woni(;ii  only  JS  in  wliich  lIk;  existing 
psyclioses  could  be  ascribed  to  an  infectious  disease,  and  among 
1270  men  only  4.  Among  4000  patients,  Rong(^^  saw  34  post- 
typhoid psychoses.  We  should  remember,  however,  that  hospital 
statistics  cannot  be  regarded  as  in  any  sense  representing  the  real 
frequency  of  these  disorders.  First,  a  large  ninnber  of  rases  do 
not  necessitate  commitment,  and  secondly,  in  hospital  admissions 
the  etiological  relation  with  typhoid  fever  is  not  always  brought 
to  the  attention  of  the  asylum  physicians. 

The  occurrence  of  typhoid  insanities  appears  to  depend,  among 
other  things,  on  the  character  of  the  individual  epidemic;  they 
occur  more  fre(juendy  in  some  e})idemics  than  in  others.  Among 
special  factors,  it  is  not  improbable  that  constipation  may  be  a 
predisposing  cause,  by  favoring  the  retention  and  absorption  of 
poisons.  However,  the  determining  factors  in  the  production  of  the 
mental  symptoms  are  unquestionably  exhaustion  on  the  one  hand 
and  toxsemia  and  bacterial  invasion^  on  the  other,  i.  e.,  diminished 
resistance  and  intoxication.  The  diminished  or  subnormal  resistance 
occurs,  of  course,  most  readily  in  those  of  neuropathic  make-up. 
Norbury^  also  lays  stress  upon  the  factor  of  heredity.  He  further 
points  out  that  the  type  of  the  psychoses  is  in  individual  cases  very 
different.  The  post-febrile  psychoses  are  only  one  group  as  regards 
their  etiology.  He  claims  to  have  observed  the  clinical  picture 
of  mania,  melancholia  and  pseudoparalytic  conditions  following 
typhoid  fever.  He  refers  all  of  these  phenomena  to  cellular  changes. 
According  to  his  interpretation,  the  cells  of  the  brain  have  their 
irritabihty  increased  or  diminished  by  the  toxin,  or  have  their 
functions  directly  changed  or  altered.  Friedlander*  who  has  made 
an  exhaustive  study  of  the  relations  existing  between  typhoid  fever 
and  mental  diseases,  also  believes  that  both  nem'otic  and  toxic 
influences  are  to  be  considered.  In  Edsall's  cases  of  t}-phoidal 
insanity  in  childhood,  heredity  did  not  seem  to  play  a  special  role. 

1  Rouge.     Annales  med.  psychol.,  1907,  Nos.  1  and  2,  pp.  5,  221. 

2  Bauduy.     St.  Louis  Courier  of  Medicine,  April,  1900. 

3  Norbury.     Journal  of  the  American  Medical  Association,  1900.  xxxv.  Xo.  4. 

*  Friedlander.  Kritisches  Sammelreferat,  Monatsschr.  f.  Psych,  u.  Xeurol.,  1900,  Band 
viii,  p.  60. 


2S4  THE  MEXTAL  COMPLICATIOXS 

FriedlJinder  has  also  studied  the  reportetl  cases  of  typhoid  fever 
occurring  among  the  insane,  and  conckules  that  there  is  no  differ- 
ence in  immunity  between  persons  mentally  sound  and  persons 
mentally  diseased. 

The  mental  disturbances  of  typhoitl  fever  are  separable  into 
three  groups:  (1)  those  which  develop  during  the  prodromal  or 
initial  period;  (2)  those  which  arise  during  the  continuance  of  the 
fever;  and  (3)  those  which  occur  during  or  subsequent  to  convales- 
cence. 

The  affections  occurring  during  the  prodromal  period  cannot  be 
definitely  separated  from  those  occurring  during  the  initial  period 
of  the  fever,  inasmuch  as  cases  beginning  in  the  prodromal  period 
may  persist  after  fever  has  made  its  appearance.  They  manifest 
themselves  in  one  of  two  forms:  (1)  a  form  in  which  mental  depres- 
sion or  mental  excitement  is  the  leading  feature,  and  (2)  a  form 
in  which  the  symptoms  are  those  of  an  acute  delirium.  The 
first  is  represented  by  a  class  to  which  CampbelP  calls  attention. 
They  begin  in  the  prodromal  period,  and  are  especially  prone  to 
occur  when  this  period  is  protracted.  They  appear  to  be  directly 
related  to  the  malaise  and  degree  of  nervous  prostration.  They 
are  not  infrequently  met  with  in  those  cases  in  which  the  fever  is 
slow  in  making  its  appearance  or  does  not  become  pronounced 
until  a  considerable  time  has  elapsed.  They  are  characterized 
by  mental  depression,  less  frequently  by  mental  excitement,  asso- 
ciated ^^^th  disordered  mental  action — probably  confusion,  with 
some  hallucinations.  It  is  not  surprising  that  the  mental  con- 
dition may  entirely  mask  the  underlying  disease.  Audemard^ 
for  a  time  made  a  serodiagnosis  of  cases  which  presented  the 
clinical  picture  of  confusion  with  excitement,  and  obtained 
positive  results  in  27  out  of  43  cases.  The  clinical  picture  is 
either  that  of  a  very  active  delirium,  that  of  confusion,  or  that  of 
depression.  Motor  disturbances  are  more  or  less  noticeable. 
Fever  may  be  present  or  absent.  Audemard  believes  that  the 
typhoid  invasion  produces  a  mengingo-encephalitis.     The  ordinary 

'  Campbell,  Colin  M.     Diet,  of  Psycholog.  Med.,  vol.  i,  p.  50G. 

2  Audemard.  Thfese  de  la  Faculty  de  Toulouse,  1898-99,  Ref.  Gaz.  liebd.  de  med.  et 
de  chir.,  November  19,  p.  93. 


THE  MENTAL  COMI'IJCATIONS  285 

[)iclurc  (-)!'  typhoid  fever  is  not  present.  M'lie  symptoiiis  nuiy  In; 
so  pronounced  as  to  lead  to  the  eommilmcnt  of  die  patient  to  the 
asylum,  the  nature  of  the  case  not  heef>niing  evident  until  later. 
It  is  extremely  probable  that  in  such  cases  there  is  a  markc^fl  hererJi- 
tary  tendency  to  insanity,  and  that  the  depression  of  the  prrxlromal 
period  of  the  fever  merely  acts  as  an  exciting  cause.  It  siujiild  be 
added  that  these  cases  are  quite  rare.  We  shoiiUl,  hr>\vever, 
remember  that  if  a  given  case  is  obscure  in  its  origin,  if  the  mental 
depression  has  developed  in  a  manner  more  rapidly  than  that  seen 
in  melancholia,  and  if  it  is  otherwise  atypical,  the  commitment 
should,  if  possible,  be  delayed  and  the  case  be  kept  under  observa- 
tion for  some  days.  The  occurrence  of  this  form  also  shows 
how  important  it  is  to  make  a  thorough  'physical  examination  of  the 
patient. 

In  the  second  form  of  mental  disorder  of  the  prodromal  or  initial 
period,  we  have  present,  as  already  stated,  the  symptoms  of  an 
acute  delirium.  This  delirium  is  characterized  by  profound 
mental  obtusion,  confusion,  and  hallucinations,  which  are  often 
terrifying  in  character.  There  are  manifestations  of  great  fear 
and  often  impulses  to  violent  acts.  In  tliis  form  violent  assault 
upon  the  person,  murder,  or  suicide  may  occur.  It  may,  indeed, 
in  rare  cases  attain  the  violence  of  typhomania^  {delirium  grave). 
(See  chapter  on  Onset.)  While  the  delirium  is  usually  accompanied 
by  terrible  hallucinations,  the  patient  seeing  frightful  objects 
and  hearing  terrifying  sounds,  it  is  under  rare  circumstances 
associated  with  expansive  ideas.  Kirn"  describes  a  case  in  which 
instead  of  depression  there  was  present  delirium  of  grandeur, 
only,  however,  to  be  followed  by  depression  later  on.  Deiters^ 
reports  two  cases  of  mental  disease  of  typhoid  origin.  Both  the 
cases  he  reports  presented  a  bad  nervous  heredity.  He  beheves 
that  this  heredity  is  of  importance  especially  in  the  appearance  of 
these  psychoses  of  invasion.  Both  cases  presented  the  symptoms 
of  an  initial  delirium,  and  Deiters  concludes  that  in  all  acute 
psychoses  which  accompany  a  febrile  invasion  we  must  always 

1  Nasse.     AUegemeine  Zeitschr.  f.  Psych.,  1870-71,  p.  11. 

'  Kirn.     Ibid.,  vol.  xxxix,  p.  741. 

s  Deiters.     Munch,  med.  Woch.,  1900,  No.  -47. 


2S6  THE  MEXTAL  COMPLICATIOXS 

think  of  a  possible  typhoid  fever.  The  initial  delirium  may 
precede  the  tlevelopment  of  the  fever  for  some  time.  The 
physical  signs  may  only  make  their  appearance  relatively  late. 

The  acute  delirium  of  the  initial  period  is  to  be  looked  upon 
as  among  the  unusual  mental  complications  of  typhoid  fever.  It 
appears  to  be  present  especially  in  certain  epidemics,  as,  for 
instance,  in  that  recorded  by  Blanc*  as  occurring  among  French 
troops  in  Tunis.  "Whether  the  delirium  actually  antedates  the 
outbreak  of  fever  is  uncertain,  inasmuch  as  accurate  temperature 
studies  are  as  yet  lacking.  It  may,  however,  continue  for  some 
time  after  the  fever  has  been  established,  and  may  merge  into  the 
ordinary  fever  delirium.  In  other  cases,  again,  it  disappears 
altogether  as  the  height  of  the  fever  is  reached.  Many  cases, 
however,  die  before  the  fever  has  fully  developed.  The  existence 
of  acute  delirium  in  the  prodromal  or  the  initial  period  of  typhoid 
fever  is  always  to  be  looked  upon  as  of  ill  omen.  According  to 
Adler,^  only  one-third  of  the  cases  presenting  this  complication 
recover. 

The  mental  complications  occurring  during  the  period  of  fever 
separate  themselves  into  (1)  the  ordinary  fever  delirium,  (2) 
expensive  or  ambitious  delirium,  and  (3)  stupor  or  coma  vigil. 
The  fever  delirium  is  ordinarily  quiet  in  type,  and,  though  at  times 
associated  with  excitement,  does  not  merit  separate  consideration 
here.  The  expansive  or  ambitious  delirium,  a  rare  form  of  compli- 
cation, may  be  present  during  the  entire  course  of  the  fever.  INIore 
frequently  it  comes  on  after  the  fever  has  passed  its  height,  and 
persists  during  the  period  of  decline.  In  such  cases  the  patient 
presents  the  picture  of  the  delirium  of  grandeur.  In  a  case 
observed  by  the  writer  the  patient  kept  talking  about  his  bags 
and  vaults  of  gold,  about  his  diamonds,  fast  horses,  and  other 
great  worldly  possessions.  The  delirium  is  not  accompanied  by 
marked  excitement,  and  disappears  with  the  defervescence  of  the 
fever.^ 

The  stupor  of  typhoid  fever,  like  the  ordinary  fever  delirium,  is 

'  Blanc.     Schmidt's  Jahrbucher,  cc.xiv. 

2  .\dler.     Allegemeine  Zeitschr.  f.  Psych.,  vol.  liii,  p.  753. 

3  Cases  have  been  reported  by  Delasiauve,  Christian,  Simon,  and  Liouville,  Diet,  of 
Psycholog.  .Med.,  vol.  ii,  p.  98G. 


Till':  MKNTAL   COMPLICATIONS  287 

SO  well  known  as  no(  (o  nicril  dcscriplion.  I(  may  onna  on  as  a 
gradual  deepening  of  the  initial  aj)atliy  and  liebctudeof  the  (Ji.sea,se, 
or  it  may  be  a  transition  from  tlic  fever  flelirium.  .More  rarely  it  is 
the  outcome  of  an  acnic  delirinni  of  the  initial  jx-iiod.  fts  oeeur- 
rence  at  an  early  stage  is  always  of  grave  signifieanee.  When 
arising  during  the  period  of  decline,  it  sometimes  cfHitinucs  long 
after  the  fever  has  subsided. 

The  insanities  which  arise  during  or  subsefjucnt  to  convales- 
cence are  those  which  principally  concern  us  here.  They  may 
arise  during  the  subsidence  of  the  fever,  anrl  may  be  merely  a 
continuation  of  the  confusion  and  delirium  of  the  febrile  stage; 
much  more  frequently  they  make  their  appearance  after  the  fever 
has  entirely  disappeared. 

Post-typhoid  insanities  may  make  their  appearance  in  one  or 
other  of  the  following  forms: 

1.  Acute  delirium. 

2.  Confusional  insanity,  stuporous  insanity.* 

3.  Cerebral  asthenia,  pseudodementia,  pseudoparesis. 

4.  Insanity  with  systematized  delusions  resembling  paranoia. 

5.  True  mania  or  true  melancholia. 

1.  Acute  Delirium. — The  acute  delirium  following  typhoid 
fever  is  indistinguishable  from  the  delirium  of  exhaustion  follo\\-ing 
other  infectious  fevers,  shock,  trauma,  or  other  profoundly  debili- 
tating causes.  It  is  characterized  by  excessive  mental  confusion, 
increased  rapidity  in  the  flow  of  ideas,  numerous  and  varied  hallu- 
cinations, obtusion  of  the  perceptive  faculties  to  both  internal 
and  external  impressions,  and  marked  motor  excitement.  The 
onset  is  usually  sudden,  and  frequently  corresponds  with,  the  ter- 
mination of  the  fever.  It  appears  to  coincide  with  the  collapse 
wliich  follows  the  disappearance  of  the  fever  in  some  cases.  At 
other  times  a  brief  interval  of  a  day  or  two  characterized  by  in- 
somnia and  ominous  restlessness  precedes  the  outbreak.  Con- 
sciousness becomes  more  obscured;  the  patient  loses  the  proper 
recognition  of  his  surroundings,  he  becomes  illusional,  everything 

1  Kraepelin  and  Regis  are  among  the  few  systematic  writers  to  fully  appreciate  the 
etiological  relation  of  tMDhoid  fever  to  these  disorders.  PagUans,  Re\Tie  de  Med.,  1S94, 
xiv,  549  and  656,  imfortunately  misinterprets,  as  did  the  older  writers,  post-tj-phoid  condi- 
tions attended  by  excitement  or  depression  as  mania  or  melancholia. 


2SS  THE  MENTAL  COMPLICATIONS 

seems  strange  and  changed,  ami  in  addition  he  becomes  hallueina- 
torv  to  an  extreme  degree.  The  chairs  and  other  objects  of  furni- 
ture are  mistaken  for  strange  shapes,  persons,  or  animals.  The 
indivitluals  about  his  bed  are  no  longer  properly  recognized; 
the  pictiu-es  upon  the  walls,  the  curtains  upon  the  windows,  the 
rugs  upon  the  floor,  all  become  animate  objects.  The  hallucina- 
tions rival  the  illusions  in  their  variety  and  number.  They  appear 
to  consist  especially  of  auditory  and  visual  sensations.  Voices 
call  to  him,  strange  persons,  horrid  creatures  gesticulate,  beckon, 
terrify  him.  It  is  not  strange  imder  these  circumstances  that  he 
appears  to  have  dreadful  and  depressive  delusions.  He  believes 
that  horrible  punishments  are  to  be  meted  out  to  him;  that  he  is 
to  be  cut,  to  be  stabbed,  to  be  poisoned,  that  he  has  only  a  short 
time  to  live.  No  wonder  that  his  struggles  are  often  merely  the 
outward  expression  of  a  frenzied  fear.  Very  rarely  the  hallucina- 
tions and  the  delusions  are  of  a  pleasurable  and  expansive  char- 
acter, the  patient  sho\\ing  by  his  demeanor,  as  well  as  by  his  speech, 
the  pleasure  that  he  feels.  Sometimes  he  is  distinctly  erotic. 
Occasionally  depressive  and  expansive  mental  states  are  present 
at  different;  times  in  the  same  case. 

The  speech  of  the  patient,  in  keeping  with  his  disturbed  mental 
condition,  is  for  the  most  part  fragmentary  and  confused,  and 
the  delusive  ideas  are  difficult,  if  not  impossible,  to  follow.  Of 
course,  the  delusions  themselves  are  fragmentary  and  unsystem- 
atized. The  patient  cries  out  or  utters  merely  parts  of  sentences 
and  phrases,  and  when  the  condition  is  fully  established,  his  words 
may  be  entirely  incoherent  or  consist  of  senseless  alliterations. 
At  other  times  he  talks  excitedly,  loudly,  pathetically,  or  whispers, 
gesticulates,  and  makes  grimaces.  It  is  generally  impossible  to 
obtain  a  rational  answer  to  a  question,  though  sometimes,  during 
a  momentary  lull,  the  patient  may  comply  with  a  given  direction. 
The  well-meant  attentions  of  the  nurse  and  friends  are  misunder- 
stood and  generally  actively  resisted.  Sleep  is  almost  abolished, 
indeed,  completely  so  in  some  cases  during  the  entire  attack. 
Food  and  medicine  are  administered  with  great  difficulty.  When 
the  food  is  placed  in  the  mouth  the  patient  may  spit  it  out,  though 
in  other  cases  it  may  be  greedily  swallowed.      As  the  delirium 


77//';   MHNTAI.   (;(>MI'IJ(:A'ri()S'H  2S9 

reaches  its  li('i<i,'lil,  llic  inind  hccoincs  iiioi'f-  ;iiii|  iiMdc  (t>\\U\s('i\, 
and  the  motor  excitement  miinifesls  itself  in  senseless  strn^'j^ling 
or  in  purposeless  and  automatic  movements,  turning  about  the  ix-d, 
aimless  gestures,  pusliing,  rubbing,  etc. 

The  |)hysieal  condition  is  indicative  of  great  weakness,  the 
color  is  j)ale,  the  surlace  oi'  the  body  is  cohl  and  often  moist,  and 
the  emaciation  of  the  typhoid  fever  is  rapidly  and  greatly  aeeent- 
uated.  The  pulse  is  small,  sometimes  slow,  sometimes  rapid;  it 
is  always  weak.  As  a  rule,  abrasions  and  ecchymoses  are  olxserved 
on  various  parts  of  the  body.  Generally  they  are  the  unavoidable 
results  of  the  patient's  struggles. 

Acute  delirium  is  a  complication  of  short  duration.  It  may 
hist  only  a  few  hours;  it  never  extends  over  more  than  a  few  days. 
Recovery  is  ushered  in  by  the  return  of  consciousness,  which  is 
generally  quite  rapid.  The  patient  begins  to  recognize  his  sur- 
roundings and  his  hallucinations  disappear.  He  begins  to  comply 
with  the  directions  of  the  nurse,  takes  his  food,  and,  above  all, 
begins  to  sleep.  As  a  rule,  the  recovery  is  steady  and  uninterrupted , 
but  at  times  it  is  broken  in  upon  by  recurrences  of  the  delirium, 
generally  transient  in  character.  Recovery  does  not,  however, 
always  ensue.  The  exhaustion  may  proceed  so  far  as  to  lead  to 
stupor,  and  the  patient  may  remain  in  this  condition  for  a  prolonged 
period  of  time.  The  final  prognosis,  however,  of  even  this  form 
of  compHcation  is  relatively  good.  The  great  majority  of  cases 
of  acute  delirium  following  typhoid  fever  recover.  However, 
emotional  irritability  and  instability,  hebetude,  and  physical 
weakness  persist  for  several  weeks  after  the  delirium  has  ceased. 
The  memory  of  the  patient  for  the  events  of  the  attack  is  much 
obscured.  He  can  seldom,  if  ever,  give  any  but  a  vague  account 
of  his  experiences. 

A  word  of  caution  may  not  be  out  of  place  here  in  regard  to  the 
too  free  use  of  alcohol  in  the  treatment  of  typhoid  fever.  The 
\\Titer  once  saw  in  consultation  a  cliild  in  wliich  the  delirium 
proved  not  to  be  a  sequel  of  the  fever,  but  was  really  due  to  the 
large  quantities  of  alcohol  wliich  had  been  administered.  A 
marked  and  typical  alcoholic  multiple  neuritis,  sthenic  in  character 
and  exquisitely  painful,  was  also  present. 
19 


290  THE  MEXTAL  COMPLICATIOXS 

2.  CoNFUSioxAL  Insanity. — The  second  form  of  post-typhoid 
insanity  to  daim  our  attention  is  confusional  insanity.  Like  the 
acute  delirium  following  typhoid  fever,  it  closely  resembles  the 
confusion  resulting  from  other  infectious  and  exhausting  disease. 
It  is  characterizetl  hy  obtusion,  mental  confusion,  incoherence 
of  ideas,  illusions,  hallucinations,  and  by  a  prolonged  course.  It 
is  much  more  frecjuently  met  with  as  a  sequel  of  typhoid  fever 
than  acute  delirium.  Typhoid  fever  most  frecjuently  induces 
exhaustion  gradually;  it  is  only  in  exceptional  cases  in  which  this 
exhaustion  comes  on  suddenly  that  acute  delirium  ensues,  liegis^ 
maintains  that  the  psychoses  whicli  make  their  appearance  in  the 
postfebrile  or  convalescent  periods  are  more  of  the  type  of  an 
asthenic  confusion.  It  is  undoubtedly  true  that  in  by  far  the  larger 
number  of  cases  the  more  slowly  acting  causes  induce  the  more 
gradual  developing  and  more  prolonged  affection  we  are  about 
to  consider.  In  keeping  with  these  statements  the  onset  is  much 
less  rapid  than  in  acute  delirium.  It  does  not  make  its  appearance 
until  some  days  after  the  fever  has  subsided;  generally,  however, 
M-ithin  the  first  week.  The  patient  becomes  nervous,  restless  and 
cannot  sleep.  5oon  he  becomes  unaccountably  afraid  and  excited, 
fears  impending  trouble  or  death,  is  obtuse,  fails  to  comprehend 
readily,  often  complains  that  he  cannot  think,  and  he  readily  be- 
comes confused.  After  several  days  the  symptoms  become  so 
pronounced  that  the  patient  begins  to  lose  the  correct  appreciation 
of  his  surroundings,  or  of  the  circumstances  in  which  he  is  placed. 
He  no  longer  knows  where  he  is,  mistakes  the  people  about  him 
for  strangers,  and  often  begs  piteously  to  be  taken  home.  To  the 
illusions  are  soon  added  hallucinations.  He  hears  threatening 
voices,  shouts,  and  cries.  He  sees  frightful  objects  or  horrible 
lookino-  men  who  load  him  with  abuse  and  curses.  As  in  acute 
delirium,  the  patient  now  believes  that  he  is  being  injured,  that 
serious  bodily  harm  is  about  to  be  done  him,  that  he  is  to  be  beaten, 
crushed,  killed.  In  addition,  the  illusions  also  play  an  important 
part,  even  greater  than  the  hallucinations.  The  patient  in  his 
condition  of  fear  is  excessively  watchful  of  his  surroundings,  which 
he  constantly  misinterprets.     The  commonest  objects  are  misun- 

'  R^gis.     Archives  de  Neurologie,  1905,  xx,  268. 


Till':  Ml':  NT  A  I.  COMJ'LICAT/OXS  201 

derstood — a  .sjjoom  is  taken  for  a  knife,  a  ilieiinoineicr  inspires 
deadly  fear,  a  Iiypodenrn'c  injection  is  re/^arded  a.s  a  savage  on- 
slaught with  a  dagger.  'J'he  patient  also  eateh(;s  worrls  anrl  phrases 
uttered  by  the  bystanders  with  surprising  readiness,  always,  of 
course,  to  inisinter])ret  them.  l*'or  tliis  reason  it  is  well  not  to 
whisper  in  the  patient's  presence,  nor  to  make  unnecessary  gestures, 
nor  to  move  about  the  room  mysteriously. 

Sometimes  it  is  possible,  by  speaking  distinctly  and  loudly,  to 
attract  the  patient's  attention  for  a  short  time.  Feeding,  when 
possible,  can  be  accomplished  by  this  means.  The  food  should 
be  urged  upon  the  patient  by  speech,  by  the  proper  presentation  of 
food  to  vision  and  to  the  lips.  Frequently,  however,  it  is  impossible 
for  many  hours  at  a  time  to  bring  the  patient  to  himself  or  to  a 
realization  of  his  surroundings  by  any  means  whatever. 

Although  the  hallucinations  are  most  frequently  of  a  terrifying 
and  depressing  character,  they  are  not  necessarily  so.  In  rare 
instances  they  are  pleasurable,  and  the  patient  may  talk  in  a  dis- 
connected way  about  his  wealth,  the  beauty  and  grandeur  of  his 
surroundings,  and  the  glorious  future  that  lies  before  him.  Such 
expansive  ideas  also  are  now^  and  then  found  in  an  intercurrent 
manner  in  the  ordinary  depressive  form.  In  keeping  with  these 
facts,  the  emotional  state  is  usually  one  of  depression  and  apprehen- 
sion, infrequendy  one  of  slight  exaltation.  Laughing  and  singing 
are  sometimes  interspersed  with  the  manifestations  of  fear,  and  at 
times  slight  eroticism  is  noticed. 

The  thoughts  are  disordered  and  tangled,  while,  as  in  the  acute 
delirium,  there  is  almost  always  some  increase  in  the  rapidity  of 
the  flow  of  ideas.  Consciousness,  as  already  stated,  is  much 
obtunded;  frequently  it  is  dream-like.  More  or  less  motor  excite- 
ment is  always  present.  It  is,  however,  much  less  marked  than 
in  the  delirium.  The  patient  is  restless,  tries  to  get  out  of  bed, 
tries  to  run  about  the  room,  struggles  at  times  to  get  away,  and  may 
exliibit  some  tendency  to  ^^olence.  In  some  cases  there  is  relative 
quiet  from  muscular  weakness  or,  perhaps,  from  inhibition.  In 
others  the  patient  holds  fast  in  a  senseless  sort  of  manner  to  siu-- 
rounding  objects  or  persons,  or  resists  in  a  semipassive  way  the 
attentions  of  the  nurse.     In  other  cases,  again,  he  betrays  evidences 


292  THE  MEXrAL  COMPLICATIONS 

of  automatism  and  tends  to  remain  for  some  time  in  the  position 
in  whicli  lie  has  been  phiced.  Symptoms  such  as  these,  however,' 
are  rehitively  infre(|uent. 

The  speech  varies  considerably.  Sometimes  whole  sentences 
are  uttered,  at  other  times  merely  phrases,  fragments,  or  inco- 
herent and  disjointetl  words.  It  is,  however,  much  easier  to  gain 
some  iilea  of  the  character  of  the  delusions  which  pass  through 
the  patient's  mind  than  in  acute  delirium;  there  they  are  largely 
a  matter  of  inference,  here  they  are  often  more  or  less  plainly 
expressed.  As  might  be  expected,  sleep  is  much  disturbed.  In- 
somnia is  always  marked,  especially  at  night.  Food  is  taken 
badly,  partly  because  it  is  not  properly  recognized  and  partly 
because  of  fear  and  the  suspicion  of  poisoning;  the  latter  idea 
has  its  groundwork  largelv  in  illusions  and  hallucinations  of 
taste  and  smell. 

The  physical  condition  of  the  patient  is,  as  a  rule,  bad.  Molnar^ 
describes  two  cases  of  acute  hallucinatory  confusion  Avhich  occiuTed 
in  the  convalescent  period  of  typhoid  fever.  In  the  first  case  there 
were  present  hereditary  factors  and  in  this  case  severe  intestinal 
bleeding  had  also  occurred.  Both  cases  recovered  at  the  end  of 
several  months.  Loss  of  flesh  is  marked,  though  rarely  as  striking 
as  in  acute  delirium.  The  surface  is  cool,  the  extremities  often 
cold,  sometimes  moist.  The  temperature  is  not  infrequently 
subnormal,^  though  it  may  be  normal  throughout.  The  pulse  is 
slow  and  lacks  force.  Now  and  then  there  is  incontinence.  The 
reflexes,  when  they  can  be  studied,  are  usually  found  exaggerated. 

The  symptoms  attain  a  maximum  in  from  two  to  three  weeks 
after  the  actual  onset.  The  subsequent  course  is  apt  to  be  irregu- 
lar, the  confusion  becoming  more  or  less  marked  by  turns;  the 
periods  of  temporary  improvement  often  correspond  to  the  taking 
of  increased  amounts  of  food,  or  follow  more  or  less  successful 
periods  of  sleep.  Convalescence  generally  sets  in  very  gradually. 
Generally  many  weeks  elapse  before  persistent  improvement  is 
noted.  The  patient  begins  for  short  periods  of  time  to  properly 
appreciate  his  surroundings  and  to  understand  what  is  said  to  him. 

»  Molniir.     Wien.  klin.  Rundschau,  1899,  No.  19,  p.  307. 

2  Wood.     University  Medical  Magazine,  December,  1889,  ii,  117. 


Tlll<:  M/'JNTAL   (:(JMJ'/JCAT/0\S  203 

The  periods  of  lucidity  gradually  Im-couic  |>ir,|<)iiu^((|  imiil,  \'i<,]n 
being  merely  of  a  few  hours'  duration,  (licy  hist  tlirr>ugli  the  gifjitr-r 
part  of  tlie  day.  Diu'iug  tli(^  eoriv;dc.scenee  the  pjificnt  is  ofh-ri 
irrital)le  and  luu-d  to  j)lc;i,s('.  Somcliiiics  traces  of  die  oM  rljstru.st 
and  suspicion  are  seen;  tlie  patient  makes  absurd  c;liarges  against 
his  nurse,  or  is  obstinate  and  intractable.  Gradually,  however,  he 
becomes  more  sensible,  more  friendly,  and  begins  to  manifest  confi- 
dence in  those  about  him.  In  many  instances,  too,  diiiin;,^  this 
period,  the  patient  is  mildly  excited  or  depressed,  wlu'le  in  f;thfrs 
some  of  the  hallucinations  persist  after  lucidity  has  made  its  apj>ear- 
ance,  but  in  such  case  the  latter  are  no  longer  made  the  basis  of  delu- 
sions. Rarely,  however,  fleeting  delusions  now  and  then  betray 
themselves.  A  valuable  index  as  to  impending  convalescence  is 
the  wiUingness  of  the  patient  to  take  food.  Partial  relapses,  it 
should  be  added,  also  occur,  especially  as  the  result  of  emotional 
excitement,  the  visits  of  importunate  and  mistaken  friends,  or  other 
imprudent  management.  The  time  occupied  by  the  course  of  the 
disease  varies  from  six  weeks  to  four  months,  and  sometimes 
longer.  By  far  the  larger  number  of  cases  recover,  provided,  of 
course,  that  they  receive  good  care  and  nursing.  Even  after 
recovery  appears  to  have  taken  place,  the  patient  may  betray 
decided  mental  weakness  and  readiness  of  fatigue.  This  asthenia 
is  often  prolonged,  and  may  persist  for  months  and,  exceptionally, 
even  for  a  year  or  more.  Death  as  a  result  of  typhoid  conf usional 
insanity,  is  very  infrequent.  Death  from  suicide  or  accident  should 
not  be  forgotten  as  a  possibility. 

Korsakow's  psychosis  which  must  be  regarded  in  spite  of  its 
memory  fabrications  and  fictions  as  merely  a  form  of  confusional 
insanity  has  also  been  observed  as  a  sequel  of  typhoid  fever.  Such 
a  case  has  been  placed  on  record  by  Soukhanoff,^  who  describes 
an  interesting  case  of  a  well-defined  Korsakow's  psychosis  which 
developed  in  a  man,  aged  thirty-four  years,  after  a  typhoid  fever. 
The  man  had  not  been  an  alcoholic  and  there  were  no  hereditary 
factors.  The  mental  symptoms  made  their  appearance  simul- 
taneously with,  the  symptoms  of  neuritis.     Soukhanoff  points  out 

'  Soukhanoff.     Journal  de  NTeurologie,  1902,  No,  7,  p.  121. 


294  THE  MEXTAL   COMPLICATIONS 

also  that  the  oldti-  tlic  patient  suffering  from  a  Korsakow's  psychosis 
is,  so  much  more  do  disorders  of  memory  become  apparent. 

Stuporous  Insanity. — Sometimes,  though  infrequently,  cases 
wliich  l)egin  as  confusional  insanity  merge  into  stupor,  the  nervous 
exhaustion  becoming  so  profound  that  the  mental  faculties  are 
finally  completely  suspended.  However,  cases  that  become 
stuporous  differ  from  the  ordinary  confusional  cases  in  the  length 
of  the  developmental  period,  and  although  a  stage  of  confusion  is 
present  preceding  the  onset  of  stupor,  this  stage  is  usually  short. 
The  stuporous  form  is,  therefore,  well  defined  clinically,  but 
bears  close  relations  to  the  form  characterized  by  confusion. 

Stuporous  insanity  is  characterized  chiefly  by  a  more  or  less 
marked  abeyance  of  the  mental  faculties.  It  is  also  known  as 
acute  dementia  or  curable  dementia.  It  is  of  extremely  gratlual 
development.  Several  weeks  usually  elapse  before  stupor  is 
established,  and  diu'ing  this  preliminary  period  the  patient  is 
nervous,  timid,  and  fearful,  sleeps  badly,  complains  of  headache, 
and  is  dull  of  comprehension.  Instead  of  gaining  in  weight,  as 
does  the  ordinary  case  of  typhoid  during  convalescence  from  the 
fever,  he  is  either  at  a  standstill  or  loses.  He  is  worried,  feels  ill, 
and  loses  his  appetite.  Soon  mental  confusion  makes  its  appear- 
ance. As  in  confusional  insanity,  the  patient  loses  the  proper 
appreciation  of  his  surroundings.  He  believes  himself  to  be  away 
from  home  and  fails  to  recognize  the  persons  about  him,  and  after 
a  time  this  inability  to  interpret  his  sm-roundings  gives  way  to  an 
inability  to  appreciate  them  at  all.  The  patient  lies  motionless 
in  bed,  indifferent  apparently  to  everytliing  about  him.  In  this 
condition  he  cannot  be  made  to  answer  questions,  and  does  not 
speak  spontaneously.  Emotionally  he  seems  placid  and  indifferent, 
though  in  some  cases  periods  are  present  during  which  transient 
emotional  movements,  excitement,  depression,  or  weeping  are 
observed.  The  face  is  relaxed,  flaccid,  and  expressionless.  He  is 
utterly  helpless.  Frequently  he  betrays  a  form  of  automatism;  he 
may  remain  for  some  time  in  the  position  in  which  he  has  been 
placed  without  moving.  Thus  the  arm  may  be  kept  elevated,  the 
fingers  extended,  or  the  head  turned  to  one  side.  These  symptoms 
are  often  spoken  of  as  cataleptoid,  but  they  have,  of  course,  no 


77/ A'   MJ'JNTAL   COM I'LICA'I'IOSS  205 

relation  with  tr(ie  cjitii,lc[).sy.  A<i;;iiM,  wliilc  llic  ;^ic;ii  iiKijority  of 
cases  iiro  niotioiiUiSS,  a  very  liinilcd  iiiniilx-r  arc  ac:f:r;iiij>uni('f|  hy 
agitation  or  purposeless  movements.  The  U'vA\\\\r  ol"  the  padf-nt 
is  often  difficult.  At  times  he  will  swallow  food  that  is  j^hieefj  In 
his  mouth,  at  other  times  he  will  allow  it  to  remain  in  the  mouth, 
makinp;  no  effort  at  swallowing,  or  will  allow  it  passively  to  escape 
upon  the  pillow.  In  many  cases  nasal  feeding  is  the  only  practi- 
cable plan  of  administering  nouiisiinient,  and,  as  a  rule,  this  can 
easily  be  carried  out  and  answers  every  possible  purpose. 

Tlie  physical  condition  of  the  patient  reveals  great  depression 
of  nutrition.  There  is  decided  loss  of  flesh,  coolness  or  coldness 
of  the  surface,  and  at  times  a  subnormal  temperature.  The 
features  are  pale,  perhaps  slightly  cyanosed.  The  extremities  are 
often  bluish  and  sometimes  oedematous.  The  pulse  is  small  and 
slow,  the  respiration  shallow.  In  women  the  menses  cease.  Like 
confusional  insanity,  stupor  is  an  affection  of  long  duration; 
several  months  are  always  required.  Convalescence  also  is  estal> 
lished  very  gradually.  The  patient  begins  by  betraying  some 
consciousness  of  his  surroundings.  He  may  attempt  to  speak  or 
make  movements  of  expression.  He  also  begins  to  take  his  food 
more  readily,  brightens  up  a  little  toward  the  latter  part  of  the  day, 
and  little  by  little  comes  into  normal  relations  with  his  environ- 
ment. Readiness  of  fatigue  persists  for  a  long  time,  and  there  are 
frequent  recurrences  of  mental  confusion  which  reveal  themselves 
either  in  the  patient's  actions  or  in  his  conversation.  Great  care 
should  be  taken  to  conserve  the  strength  of  the  patient  as  much  as 
possible  by  the  avoidance  of  excitement  or  of  visitors.  While  by 
far  the  greater  number  of  cases  end  in  recovery,  tliis  is  not  the 
invariable  rule.  A  few  cases  pass  into  permanent  dementia; 
in  others  some  permanent  mental  impairment  persists,  and  in  a 
smaller  number  death  results,  due  either  to  the  gravity  of  the 
exhaustion  or  to  some  visceral  complication. 

3.  Cerebkal  Asthenia,  rsEUDODE:MEXTiA,  Pseudoparesis. 
— More  frequently,  perhaps,  than  any  other  complication,  we  have 
folloT\ing  typhoid  fever  a  condition  of  general  mental  enfeeblement. 
This  is  generally  of  short  dm'ation,  but  is  sometimes  excessively 
prolonged.     There  is  present  in  such  cases  a  slight,  though  unmis- 


29G  THE  MENTAL  COMPLICATIONS 

takable,  weakness  of  the  intelligence,  together  with  abnormal 
excitability  and  loss  or  impairment  of  emotional  control.  The 
patient  does  not  comprehend  as  readily  as  normally,  is  incapable 
of  sustained  effort,  lacks  spontaneity  of  thought,  and  laughs  or 
cries  on  relatively  slight  provocation.  He  is  also  very  readily 
fatigued.  At  times  there  is  in  addition  a  diminution  in  the  facility 
and  readiness  of  speech.  Physical  symptoms  indicative  of  weak- 
ness are  also  present — e.  g.,  coldness  of  the  extremities,  cardiac 
palpitation,  atonic  indigestion,  and  persistent  sleep  disturbances. 
This  cerebral  asthenia  for  some  unexplained  reason,  occasionally 
follows  comparatively  mild  attacks  of  the  fever,  and  may  be  very 
marked.  In  other  cases,  again,  in  which  the  attack  has  apparently 
been  of  great  severity,  these  symptoms  may  be  entirely  absent. 

Instead  of  a  mere  mental  weakness  and  anenergia,  actual  mental 
obtusion  may  be  present,  and  this  mental  obtusion  may  become 
so  pronounced  as  to  lead  to  great  impairment  of  all  of  the  mental 
faculties — a  form  of  dementia.  This  is  not,  however,  a  true 
dementia,  but  one  in  which  the  mental  faculties  are  merely  suspen- 
ded, not  obliterated.  It  is  properly  termed  a  pseudodementia. 
This  pseudodementia  lasts  many  months  and  at  times  even  one  or 
two  years.  Recovery  follows  in  the  majority  of  cases,  but  is  very 
gradual.  Sometimes  it  is  incomplete,  permanent  mental  impair- 
ment resulting.  Every  now  and  then  there  are  added  to  this  back- 
ground of  dementia  symptoms  which  closely  resemble  those  of 
paresis.  Thus  there  may  be  present  great  muscular  weakness, 
ataxia  of  movement,  tremor  of  the  lips,  face,  or  extremities,^  and 
to  the  condition  of  obtusion,  hebetude,  and  mental  weakness 
already  present,  there  may  be  added  absurd  and  ambitious  delu- 
sions. This  feeble,  expansive  state  makes  the  resemblance  to 
paresis  appear  very  striking  and  often  misleading.  The  pseudo- 
paresis  of  typhoid  fever  may  occasion  difficulty  in  diagnosis  if  the 
physician  be  in  ignorance  of  the  etiology.  However,  the  detailed 
history  of  the  case,  the  presence  or  absence  of  the  Argyll-Robertson 
pupil,  the  condition  of  the  optic  nerve  as  revealed  by  the  ophthal- 
moscope, are  among  the  factors  which  should  be  considered. 
Pseudoparesis  following  typhoid  fever  almost  always  terminates 

1  Christian,  Westphal,  R^gis. 


Till':  Mh'NTAL  COMl'LICATIOXS  207 

in  recovery;  l)osi(]e,s,  the  course;  of  tli('(H,sea.se  is  cJifferent  fivMii  that 
of  paresis.     The  mental  loss,  too,  is  Jiot  as  profound  or  as  real. 

4.  Insanity  with  Systkmatizkd  Delusions  IIkskmuling 
Paranoia. — A  very  h'milcd  nimilx  r  of  cases  oi'  insaiiify  following 
tyj)hoi(l  fever  })res('iit  a  series  of  nioix*  or  less  well-systcinatized 
delusions.  These  delusions  are  at  times  remains  of  the  fever  de- 
lirium M^hich  have  persisted.  At  other  times  they  arise  during 
convalescence.  The  patient  may  give  well-connected  accounts  of 
frightful  persecutions,  of  murders,  hangings,  etc.  The  delusions 
are  almost  invariably  of  a  depressive  character,  and  appear  to  be 
connected  with  painful  or  terrifying  hallucinations.  Such  cases 
have  been  described  by  Miiller,^  Hurd,^  and  others.  They  are 
distinguished  from  true  paranoia  not  only  by  the  peculiar  etiology, 
but  also  by  the  fact  that  the  delusions  are  not  firmly  fixed,  but 
often  shifting  in  character,  and  also  by  the  fact  that  sooner  or 
later,  as  soon  as  the  general  condition  of  the  patient  improves, 
the  delusions  vanish.  Recovery  may,  however,  not  always  ensue, 
and  progressive  mental  impairment,  with  final  dementia,  may  be 
the  result.     Such  an  outcome,  however,  appears  to  be  exceptional. 

5.  True  Mania  pr  True  Melancholia. — In  addition  to  the 
various  forms  of  mental  disorder  above  described,  and  which  are 
evidently  associated  with  the  excessive  nervous  weakness  and, 
perhaps,  the  profound  intoxication  of  the  typhoid  infection,  pure 
insanities  are  every  now  and  then  observed.  In  other  words,  true 
mania  or  true  melancholia  may  arise  subsequent  to  typhoid  fever. 
Owing  to  the  loose  way  in  which  the  terms  mania  and  melancholia 
are  employed  by  many  medical  writers,  many  cases  of  so-called 
mania  and  melancholia  have  been  placed  upon  record  as  resulting 
from  typhoid  fever.  A  close  examination,  however,  reveals  that 
they  are  in  most  instances  cases  of  an  insanity  of  exhaustion, 
generally  confusional  insanity,  which  have  been  classed  as  mania 
or  melancholia,  according  to  the  presence  of  mental  excitement  on 
the  one  hand,  or  mental  depression  on  the  other.  Pure  mania  or 
pure  melancholia,  as  a  result  of  typical  typhoid  fever,  is  excessively 
rare.  For  instance,  .typical  melancholia  with  excessive  psvcliic 
pain  and  self-accusatory  delusions,  as  typified  by  the  delusion  of 

1  Miiller.     Loc.  cit.  -  Hurd.     .Ajnerican  Journal  of  Insanity,  July.  1S92. 


298  THE  MEXTAL  COMPLICATIOXS 

the  unpardonable  sin,  is  almost  never  met  with.  This  is  also  true 
of  pure  mania  as  typified  bv  excessive  exaltation,  expansion,  and 
increased  rapidity  in  the  flow  of  ideas,  without  hallucinations  or 
confusion.  Further,  cases  of  the  pure  insanities  follo\Aing  typhoid 
fever  do  not,  as  a  rule,  like  the  insanities  of  exhaustion,  develop 
iuunodiately  after  or  ^^•ithin  a  short  period  of  the  defervescence  of 
the  fever,  but  at  rather  later  periods — weeks  anil  months  afterward. 
It  is  exceedingly  probable  that  when  a  pure  insanity  does  follow 
typhoid  fever  it  is  an  indirect  sequel.  In  other  words,  the  post- 
tvphoid  condition  of  asthenia  merely  offers  a  suitable  soil  in  which 
true  mania  or  true  melancholia  may  develop  in  subjects  predis- 
posed to  these  affections  by  heredity.  We  should  remember  that 
mania  and  melancholia  are  largely  determined  by  heredity,  and 
only  need  a  condition  of  depraved  nervous  nutrition  in  order  to 
make  themselves  manifest. 

Prognosis  in  General. — The  prognosis  of  the  various  mental 
complications  of  typhoid  fever  depends  largely  upon  the  period 
at  wliich  the  symptoms  appear.  Prodromal  insanity,  especially 
grave  prodromal  delirium,  tends  in  a  large  number  of  cases — one- 
third  according  to  Adler — to  end  fatally.  The  prognosis  of  the 
comphcations  arising  dming  the  fever  is  almost  uniformly  good. 
The  fever-dehrium,  the  confusion,  the  expansive  and  ambitious 
ideas  vanish  with  the  disappearance  of  the  fever.  The  various 
forms  of  mental  derangement  w'hich  occur  as  sequelre  of  typhoid 
fever  also  offer  a  favorable  prognosis  as  a  wdiole.  The  great 
majority  of  cases  of  post-typhoid  confusional  or  stuporous  insanity 
make  a  good  recovery,  but  this  is  not  by  any  means  the  constant 
result.  Instead  of  a  continuous  progress  toward  recovery,  there 
may  be  a  series  of  relapses,  follow^ed  by  incomplete  recovery,  or 
cases  may  pass  into  hopeless  clironicity  and  dementia.  This, 
how^ever,  as  has  already  been  pointed  out,  is  the  outcome  in  a  small 
percentage  of  cases  only.  Pilgrim^  states  that  in  his  opinion  only 
about  50  per  cent,  of  cases  due  to  typhoid  fever  recover,  wliile  20 
per  cent,  die  from  exhaustion,  and  30  per  cent,  gravitate  into 
clironic  insanity.     These  statements,  however,  are  not  borne  out 

1  Pilgrim.     State  Hospital  Bulletin,  Utica,  New  York,  1896,  i,  50. 


Ph'OCNOS/S  IN  a  EN  ERA  L  209 

by  \}h'.  ('Xpcriciicc  oiil.siMc  of  (lie  ;i,syiiim.s.  Tlic  jjcrfci]l;i;.'('  ol' 
favorable  rcstiMs  is  really  iiiueli  <^i'ea(,er. 

The  EiTECT  of  Typhoid  Fevkii  ox  J'jik-kxih'J'ing  Txhantty. 
— It  may  be  not  uninteresting  to  add  a  paragraph  as  (o  the  re- 
markable efFects  which  follow  typhoid  fever  when  attacking  those 
who  are  already  insane.  In  quite  a  number  of  such  cases,  irre- 
spective of  the  special  form  of  insanity,  recovery  follows  typhoid 
fever.  In  others,  again,  long-continued  improvement  ensues;  in 
a  smaller  number  temporary  improvement,  and  in  others  still  no 
change  whatever  is  observed.  Nasse/  Wise,^  Keay,^  Charon,'  and 
others  have  placed  on  record  quite  a  number  of  cases  of  recovery.'' 
Friedlander"  has  also  studied  this  subject,  and  has,  like  others, 
noted  a  recovery  from  mental  disease  after  attacks  of  typhoid 
fever.  Frequently  in  such  cases  the  mental  recovery  does  not 
take  place  during  the  period  of  convalescence,  but  only  some 
time  after  convalescence  from  the  latter  has  been  completed; 
sometimes  after  many  months.  Paris^  differentiates  between  the 
febrile  deliria  and  the  true  psychoses,  and  calls  attention  to  the 
fact  that  during  an  attack  of  typhoid  fever  psychic  and  epileptic 
disturbances  subside;  that  typhoid  fever,  when  invading  insane 
asylums,  attacks  only  the  youtliful  cases  and  cases  of  recent 
admission,  and,  furthermore,  typhoid  fever  is  infrequent  in  insane 
asylums,  and  that  there  is,  therefore,  really  a  pronounced  antagon- 
ism between  the  psychoses  and  typhoid  fever.  The  author  has 
apparently  not  taken  into  account  the  studies  of  Fried  lander. 

The  interesting  fact  of  recovery  from  insanity  after  typhoid  fever 
is  comparable  to  the  effects  of  other  infectious  processes,  such  as 
erysipelas,  and  also  to  the  results  occasionally  follo^dng  trauma 
and  surgical  operations  on  the  insane.  Even  in  so  grave  a  mental 
disease  as  paresis,  an  attack  of  erysipelas  or  a  trauma  is  occasion- 
ally followed  by  a  striking  and  remarkable  remission  of  symptoms; 

*  Nasse.     Loc.  cit. 

2  Wise.     State  Hospital  Bulletin.  I'tica,  New  York,  1S96,  i,  63. 
^  Keay.     Journal  of  Mental  Sciences,  1S96,  xlii,  267. 

*  Charon.     Arch,  de  Neurol.,  1S96,  i,  330. 

5  Hja^ert,  Arch,  de  Neurol.,  1895,  vi,  103,  believes  on    the  other   hand,  that   tj-phoid 
fever  atfects  the  mental  state  of  the  insane  to  a  less  degree  than  do  other  infections. 
8  Friedliinder.     Loc.  cit. 
7  Paris.     Le  Progr&s  medical,  1902.  No.  24. 


300  THE  MEXTAL  COMPLICATIONS 

similar  statements  may  be  made  with  regard  to  melancholia  and 
other  forms  of  mental  disease  associated  Avith  depression  and 
impaired  nutrition.  In  cases  in  which  typhoid  fever  fails  to 
cure  or  to  improve  the  mental  symptoms,  the  psychosis  already 
present  does  not  appear  to  be  affected  injuriously.  At  least  this 
is  Nasse's^  conclusion.  One  case  under  the  observation  of  this 
writer  presented  a  paroxj'sm  of  delirium  of  short  duration;  in  none 
of  the  others,  five  in  number,  in  which  the  typhoid  infection  failed 
to  cure  the  insanity,  did  any  unfavorable  result  supervene.  Nasse 
further  observed  a  greater  percentage  of  recoveries  from  typhoid 
fever  in  the  insane  than  among  the  hospital  attendants.  Wise,^ 
on  the  other  hand,  found  the  mortality  30  per  cent,  among  the 
insane  and  24  per  cent,  among  the  employees.  These  data 
evidently  do  not  point  to  any  lessened  degree  of  vulnerability 
on  the  part  of  the  insane. 

1  Nasse.     Hj'^'ert,  Arch,  de  Neurol.,  1895,  vi,  103. 

^  Wise.     State  Hospital  Bulletin,  L'tica,  New  York,  i,  69. 


PART    II. 


COMPLICATIONS  AND  SEQUELS  OF  THE  ERUI*- 

TIVE  FEVERS  OTHER  THAN  TYPHOII) 

FEVEll. 


CHAPTER    L 

VARIOLA. 

Incidence  and  Susceptibility. — The  practice  of  vaccination  and 
revaccination  has  rendered  smallpox,  as  a  cause  of  death  in  the 
United  States,  and  in  all  other  countries  where  vaccination  is 
constantly  practised,  of  comparatively  slight  incidence.  Never- 
theless, the  disease  is  always  interesting  because  of  its  periodic 
outbreaks  wherever  an  unvaccinated  community  is  exposed  to  the 
infection. 

There  are  three  causes  for  the  appearance  of  sporadic  cases  of 
smallpox.  The  first,  and  by  far  the  most  important  cause,  is  the 
neglect  of  successful  vaccination  of  every  individual.  The  second 
cause  is  the  neglect  of  the  act  of  revaccination  at  stated  periods 
through  life,  particularly  during  the  presence  of  an  epidemic;  and 
the  third,  and  much  less  important,  cause  is  unusual  susceptibility 
of  certain  persons  to  the  infection.  That  there  are  persons  that 
are  unusually  susceptible  to  variola  there  can  be  no  doubt,  but, 
of  cpurse,  if  such  persons  were  vaccinated  with  an  active  vaccine 
at  various  times,  this  susceptibility  might  readily  be  done  away  with. 
As  illustrative  of  the  occurrence  of  extraordinary  susceptibility,  a 
case  reported  by  James^  may  be  cited. 

A  young  mother  had  variola  six  months  before  the  birth  of  her 

1  James.     Lancet,  January  1,  1902. 


302  YAEIOLA 

child,  -which  showed  a  few  variolous  scars  at  birth.  This  child  was 
unsuccessfully  vaccinated  after  birth,  and  again  at  nine  and  at 
fourteen  years  of  age  without  result,  but  at  the  age  of  eighteen  years 
she  contracted  hemorrhagic  variola  and  died.  It  is  quite  possible 
that  the  vaccine  used  in  the  attempted  vaccinations  was  not  active, 
but  the  case  is  an  interesting  and  unique  one. 

The  annual  average  death-rate  of  variola  in  the  United  States 
was  3.4  per  100,000  population,  from  1901  to  1905,  which  means 
that  vaccination,  revaccination,  and  quarantine  has  practically 
eradicated  the  tlisease. 

Prodromal  rashes  and  dermal  complications  are,  as  might 
be  expected  from  the  nature  of  the  disease,  the  most  common 
complications  of  variola.  In  the  early  stages  of  the  infection  the 
prodromal  rashes  are  of  immense  importance.  These  rashes  vary 
widely  in  type  and  often  serve  to  obscure  the  true  diagnosis  for 
hours,  and,  it  may  be,  for  several  days.  The  frequency  of  such 
rashes  varies  in  different  epidemics.  During  the  widespread  and 
severe  epidemic  of  1871-72,  in  America,  they  were  very  common, 
being  observed  in  13  per  cent,  of  the  cases  observed  by  Osier  in 
iSIontreal.  These  prodromal  rashes  are  not,  however,  commonly 
seen  in  smallpox  hospitals,  as  they  generally  disappear  before  the 
appearance  of  the  true  variolous  eruption  wliich  causes  the  admis- 
sion of  the  patient  to  such  an  institution. 

These  initial  rashes  in  variola  have  recently  received  deserved 
attention  in  an  excellent  paper  by  Thomson  and  Brownlee.^  In 
this  paper,  which  is  a  most  exhaustive  treatise  upon  the  subject, 
the  authors  divide  the  rashes  into  (1)  general  erythemata,  (2)  local 
erythemata,  (3)  petechioid  eruptions,  (4)  petechial  rashes,  (5) 
vesicular,  (6)  bullous,  and  (7)  composite  prodromal  rashes. 

The  general  erythemata  are  as  follows:  (a)  Morbilliform,  (6) 
scarlatiniform,  (c)  erysipelatous,  (d)  livid  erythemata,  (e)  urticaria. 

The  local  erythemata  are  as  follows :  (a)  Pale,  simple  erythemata, 
(6)  capintoid  erythemata,  (c)  erysipelatous  erythemata.  Prodromal 
rashes  are  more  often  seen  in  cases  of  varioloid  than  in  patients 
suffering  from  variola.  They  usually  develop  upon  the  second  day 
of  the  fever,  and  they  commonly  disappear  in  from  twenty-four  to 

1  Thomson  and  Brownlee.     Quarterly  Journal  of  Medicine,  January,  1909,  vol.  ii.  No.  6 


PROUUOMAL  RASJ/J'JS  AND  DERMAL  (JOM J'DKJATIOSS      ■/,{)'/, 

forty-oi;^}it  lioiirs.  TIk;  rashes  rri.'iy,  however,  iv-iiKiin  ('.ci;!!  (Jays 
after  the  appearance  of  the  true  variolous  rash. 

The  morbilliform  rrupiion  is  llic  mosl  (•((ininon  lypc'  <,\'  iiiiii;il 
rash.  The  eruption  is  irreguhirly  (Hstrihtilcd,  hciiif^  al  limc^  limited 
to  a,  small  poriion  of  the  body  and  at  other  times  generaiizech  Jt 
differs  from  the  ordinary  eruption  of  measles  in  heing  less  elevateri 
above  the  skin  and  searcely  pereeptible  when  (he  finger  is  passerJ 
over  it. 

The  scarlalinijorm  eruption  is  next  in  fre(|ijency  to  the  j-ash  whicli 
resembles  measles.  It  may  involve  a  large  part  of  the  cutaneous 
surface,  or  may  affect  certain  areas,  as  the  thighs,  the  iii;^iiinal 
rcffion,  the  extensor  surfaces  of  the  extremities,  and  the  trunk. 

Rashes  of  this  variety  are  not  infrequently  mistaken  for  the  scar- 
latinal rash  which  sometimes  accompanies  an  attack  of  typhoid 
fever  as  well  as  for  the  ordinary  rash  of  scarlet  fever. 

The  petechial  or  hemorrhagic  initial  rash  is  especially  liable  to 
appear  in  certain  well-defined  regions  of  the  body.  This  distri- 
bution has  been  carefully  studied  by  Simon,  of  Hamburg,  who 
pointed  out  the  frequency  of  this  eruption  on  the  lower  abdominal, 
inguinal,  and  genital  regions  and  on  the  inner  aspects  of  the  thighs. 
The  axillary  region  as  well  as  the  lateral  surfaces  of  the  chest  and 
abdomen  are  also  affected.  The  eruption  consists  of  pin-point 
to  pin-head  purplish  spots  closely  aggregated,  which  gives  the  skin 
the  appearance  of  a  diffuse  redness,  and  as  this  redness  is  due  to 
minute  hemorrhages  into  the  skin,  the  discoloration  does  not  dis- 
appear upon  pressure.  The  petechial  rashes  are  sometimes  seen 
in  cases  which  prove  to  be  quite  mild,  but  more  often  they  are 
found  in  cases  which  become  hemorrhagic  in  type  and  malignant 
in  character.  Rashes  other  than  those  mentioned  are  rarely  seen, 
and  composite  prodromal  eruptions  are  only  occasionally  observed. 

The  conditions  of  the  skin  which  develop  as  complications,  other 
than  the  prodromal  rashes,  are  often  of  grave  importance. 

Septic  eruptions,  in  distinction  from  septic  infection  of  the  skin 
during;  variola,  were  first  described  bv  Simon^  in  1S73,  and  have 
since  received  careful  attention  by  JNIeredith  Richards,-  Welch  and 

1  Simon.     Archiv  f.  Derniatologie  u.  Snihilis.  1S96.  p.  31. 

-  Meredith  Richards.     Quarterlj"  Journal  of  Medicine,  1S73.  p.  115. 


304  VARIOLA 

Schamberg/  and  other  writers.  During  the  epidemic  of  1901  to 
1903,  in  Phihulelphia,  Welch  and  Schamberg  observed  septic 
rashes  at  the  height  of  the  disease  in  from  o  to  8  per  cent,  of  the 
cases  admitted  to  the  ^Municipal  Hospital.  These  rashes  are 
undoubtedly  due  to  the  action  of  bacterial  toxins. 

Jn  distinction  from  the  rashes  that  are  due  to  the  absorption  of 
toxic  material  during  the  disease,  we  have  the  secondary  pyogenic 
infections  of  the  skin.  Among  these  are  impetiginous  lesions,  boils, 
and  sulicutaneous  abscesses,  large  and  small,  carbuncles,  erysipelas, 
and  cellulitis,  with  the  occasional  occurrence  of  gangrene  of  the 
skin. 

Durine  the  stage  of  incrustation  and  desiccation  in  variola  it  is 
common  to  have  impetiginous  areas  develop;  in  fact,  it  is  unusual 
to  have  a  patient  convalesce  from  unmodified  variola  without  the 
occurrence  of  such  skin  lesions.  Hebra^  called  these  lesions 
"impetigo  variolosa,"  and  the  same  term  has  been  used  by  Welch 
and  Schamberg. 

In  cases  where  there  is  a  large  extent  of  skin  affected  with  these 
sores  there  is  often  a  considerable  rise  in  temperature  and  other 
evidences  of  septic  absorption,  and  this  may,  very  rarely,  bring 
about  the  death  of  a  patient  who  is  apparently  convalescing  from 
the  original  illness.  Welch  and  Schamberg^  have  reported  an 
instance  of  this  kind  in  a  woman,  aged  sixty  years. 

Boils  and  Subcutaneous  Abscesses. — Boils  and  subcutaneous 
abscesses  are  the  next  most  frequent  complications  or  sequels 
met  Anth  in  variola.  It  is  very  unusual  for  a  patient  to  pass 
throuo-h  an  attack  of  unmodified  variola  without  suffering  from 
these  troublesome  complications  during  the  convalescence  from  the 
disease.  Even  patients  who  have  variola  which  has  been  modified 
by  early  vaccination  often  suffer  from  boils.  They  usually 
develop  during  the  interval  from  the  twentieth  to  the  thirtieth  day 
of  the  illness,  and  are  most  frequently  situated  on  the  extremities, 
although  the  face,  scalp,  and  the  back  are  also  affected.  They  vary 
in  size  from  that  of  a  bean  to  that  of  a  small  orange.     They 

1  Welch  and  Schamberg.     Acute  Contagious  Diseases,  pp.  196  to  198. 

2  Hebra.     Diseases  of  the  Skin,  p.  231. 

'  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  193. 


PRODROMAL  UASII/'JS   AND  DERMAL  COMJ'L/CA'J/OXS     :',{):) 

are  not  attended  by  great  pain  or  by  much  constitwdonal  disfiirh- 
ance,  })ut  they  are  often  present  in  large  nuinhcrs.  1 1,  is  not 
unusual  for  a  patient  during  convaleseenef;  frf)rn  variohi  lo  fiuve 
froin  five  to  fifteen  boils  incised  cadi  iiioiiiiii;^  for  days,  and  die 
total  number  incised  often  exceeds  oik;  himdrcd.  In  rjistinctifjn 
from  boils,  large  abscesses  on  the  shoulders,  hips,  limbs,  and  neck 
often  develop,  usually  in  conjunction  with  the  boils,  as  well  as 
smaller  abscesses  in  other  portions  of  [lie  borly.  d'hese  abscesses 
differ  from  furuncles  in  that  they  are  extremely  jxiinful  and  are 
accompanied  by  septic  symptoms,  which  are  sometimes  severe 
enough  to  cause  the  death  of  the  patient,  who  has  already  been 
greatly  weakened  by  the  primary  disease.  Moore^  reports  a  case 
of  variola  under  his  care  at  the  Dublin  Fever  Hospital,  in  which 
forty-two  abscesses  followed  an  attack  of  confluent  smallpox,  the 
patient  being  confined  to  bed  for  nine  months  before  recovery 
took  place.  The  junior  author  remembers  a  similar  case  at  the 
Municipal  Hospital  of  Philadelphia,  in  the  winter  of  1903,  in  which 
a  frail,  aneemic,  little  woman,  after  passing  through  an  unusually 
severe  attack  of  variola,  developed  abscess  after  abscess,  and  finally 
recovered  after  having  had  thirty  large  abscesses  drained  and 
scores  of  smaller  abscesses  and  furuncles  opened  on  all 
parts  of  her  body.  Castellvi^  had  the  unusual  experience  of 
observing  a  patient  develop  a  psoas  abscess  while  convalescing 
from  variola. 

True  carbuncles  are  rare  complications  of  variola.  Welch  and 
Schamberg,^  in  their  extensive  experience  with  tliis  disease,  are  only 
able  to  recall  one  instance  in  which  a  carbuncle  developed. 

Erysipelas.— Erysipelas  also  rarely  complicates  variola,  bu,t 
when  it  appears  it  usually  develops  at  the  end  of  the  second  or  in 
the  beginning  of  the  third  week  of  the  disease.  The  face  is  the 
region  usually  aflfected,  although  the  extremities  sometimes  suffer. 
When  we  consider  the  septic  nature  of  the  original  disease,  the 
multiple  abrasions  of  the  skin,  and  the  weakened  condition  of  the 
patient,  it  is  surprising  that  erysipelas  is  so  rarely  seen.     Welch 

1  Moore.     Twentieth  Century  Practice  of  Medicine.^lSQS.  xiii,  428. 

-  Castellvi.     Ann.  de  Obst.,  Ginecopat.,  y.  Pediat.  (Madrid,  189S),  pp.  193  201. 

s  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  230. 

20 


306  YAEIOLA 

and  Schamberg^  saw  l)ut  ten  cases  of  tliis  condition  in  2000  cases  of 
variola. 

Cellulitis. — Cellulitis,  Avhieh  usnally  affects  the  extremities, 
not  infrequently  complicates  confluent  cases  of  variola  during  the 
stage  of  decrustation.  This  cellulitis  may  involve  a  small  area,  but 
more  often  it  is  widespread,  the  condition  extending  tleeply  and 
often  spreading  over  nearly  the  entire  liinl).  The  affected  part  is 
red,  brawny,  and  hot  to  the  touch  and  extensive  sloughing  of  the 
tissues  often  occurs  even  when  free  incisions  are  made.  Not 
infrecjuently  these  conditions  prove  fatal  in  patients  whose  resist- 
ance has  been  greatly  lowered  by  the  primary  variolous  attack. 

Gangrene  of  the  Skin. — Gangrene  of  die  skin  during  variola 
may  be  produced  in  certain  cases  by  the  swelling  and  inflammation, 
and  gangrene  of  the  subcutaneous  tissues  may  result  from  the 
undermining  of  such  tissues  by  the  pus  from  unrelieved  abscesses. 
jNIarson"  has  noted  gangrene  of  the  genitals  of  women  during  severe 
attacks  of  variola.  Gangrene  of  the  scrotiun  diu'ing  variola  occurs 
only  in  very  severe  attacks  of  the  disease,  and  the  majority  of  the 
patients  thus  affected  die.  The  complication  usually  begins  as 
an  oedematous  swelling  of  the  scrotum,  which  is  rapidly  followed  by 
sloughing,  and  most  commonly  this  develops  at  the  end  of  the  second 
or  the  beginning  of  the  third  w^eek  of  the  disease.  Gangrene  of  the 
skin,  other  than  that  of  the  genitals,  affects  isolated  areas,  usually 
those  portions  which  are  subject^  to  pressure,  and  is  only  seen  in 
severe  forms  of  the  disease.  Welch  and  Schamberg  saw,  during 
the  epidemic  of  1901  and  1902,  three  cases  of  gangrene  of  the 
scrotum  and  five  cases  of  gangrene  of  the  skin  of  the  thigh.  In 
four  cases  of  the  latter  complication  recovery  ensued. 

Scarring. — Scarring  after  smallpox  occurs  in  practically  every 
confluent  case  of  the  disease.  The  extent  of  the  scarring  depends 
entirely  upon  the  depth  to  which  the  inflammatory  lesions  extended. 
After  the  lapse  of  several  months  the  scars  assume  a  whitish  color, 
paler  than  the  surrounding  skin.  The  scar  may  be  of  any  size  or 
shape,  according  to  the  shape  and  the  grouping  of  the  lesions  which 
caused  it. 

'  Welch  and  Schamberg.     Loc.  cit. 

2  Marson.     Quoted  by  Moore  Twentieth  Century  Practice  of  Medicine. 

'  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  231. 


oca  LA  u  L/uS/ONS  DUinsc  vmhoi.a  ;^,f)7 

Ar>oi'KClA. — Al()j)('ci;i,  is  ;i  vrry  i'rc(jiicii(  ,sc(|iic|  of  \;iriol;i.  A  ,  in 
other  severe  febrile  diseases,  the  hair  of  \\\c  hcnd,  heanl,  and  the 
eye})rows  may  he  lost  after  the  terinin;i(i(»ii  of  ;i  s<!vere  atf;K-k. 
This  is  partieularly  true  if  the  eniption  luis  hccn  f)rofuse  in  the 
areas  normally  covered  hy  hair.  The  loss  of  the  h;iir  is  due  as 
much  to  th(^  f(>l)rile  processes  as  to  the  local  iiifiiiciifc  of  the  cnifi- 
tion.  liestoration  of  the  hair  usually  occurs  and  is  connnf>rdy 
complete,  exce})t  in  areas  in  wiiich  the  pa|)ill;i'  of  (he  hair  have 
been  destroyed  by  the  variolous  lesions. 

The  loss  of  the  nails  from  both  fingers  and  toes  is  seen  in  a 
certain  number  of  severe  cases  and  is  usually  brought  about  by 
injury  to  the  matrix,  after  which  the  new  nail  slowly  displaces 
the  old. 

Ocular  Lesions  during  Variola. — Ocular  lesions  rluring  variola 
are  common,  but  since  Jenner's  discovery  of  tlie  protective 
influence  of  vaccination  the  destructive  action  of  smallpox  upon 
the  eye  has  greatly  lessened.  There  are,  however,  certain  compli- 
cations which  still  commonly  affect  these  organs.  Burton  Chance^ 
analyzed  over  2000  cases  of  variola  that  were  treated  at  the  ]\Iunici- 
pal  Hospital  of  Philadelphia,  and  states  that  among  the  common 
complications  he  found  pustulation  of  the  edges  of  the  lid.  Con- 
junctivitis often  accompanied  this  pustulation,  but  in  many  cases 
conjunctivitis  appeared  independently  of  the  pustulation.  In  the 
2000  cases  analyzed  there  were  a  very  large  percentage  of  cases 
showing  conjunctivitis,  which  bears  out  what  has  been  pointed  out 
many  times — that  it  is  rare  to  have  a  patient  suffer  a  severe  attack 
of  variola  without  there  being  an  associated  conjunctivitis. 

In  this  large  series  of  cases  analyzed  by  Chance  there  are  men- 
tioned only  36  instances  of  corneal  ulcer.  Of  these  36  cases,  17 
were  follow^ed  by  perforation  of  the  cornea,  with  destruction  of 
the  eyeball,  while  15  recovered  without  perforation.  Ten  cases  of 
iritis  were  seen  in  this  series.  Chance  found  that  a  common  cause 
of  corneal  ulceration  in  variola  was  the  extensive  swelling  of  the 
eyelids  due  to  the  pustular  eruption  upon  them.  So  great  was  this 
swelling  that  the  eyes,  in  many  instances,  were  opened  by  the 
attendant  only  with  great  difficulty. 

1  Chance.     In  Welch  and  Schamberg,  loc.  cit.,  p.  231. 


308  VARIOLA 

Notwithstanding  the  above  statistics  as  to  corneal  ulceration, 
we  beheve  that  keratitis  is  a  comparatively  common  occurrence 
during  variola,  especially  in  confluent  cases,  and  is  most  commonly 
seen  in  badly  nourishetl  children.  It  is  due,  at  least  in  part,  to 
traumatism  by  the  rubbino-  of  the  face  and  eyes  against  the  pillow 
and  the  consequent  scratching  of  the  vesicles. 

Corneal  ulcers  most  commonly  occur  in  the  later  stages  of  the 
disease,  and  usually  affect  one  eye,  or,  if  both  eyes  are  affected,  one 
is  usually  less  severely  involved  than  the  other. 

Blindness  due  to  smallpox  usually  arises  as  the  result  of  corneal 
ulceration. 

A  rare  cause  of  both  conjunctivitis  and  corneal  ulceration  din-ing 
variola  is  the  presence  of  variolous  lesions  upon  the  conjunctiva". 
These  occurred  in  but  tlu*ee  of  Chance's  2000  cases.  Marson^  in 
reviewing  the  notes  of  15,000  cases  of  variola,  found  only  26  cases 
in  which  the  primary  smallpox  pustule  had  been  seen  on  the  con- 
junctiva^.  Dufour  states  that  from  10  to  15  per  cent,  of  variolous 
subjects  have  ocular  lesions,  and  that  in  30  per  cent,  the  cornea  is 
involved.  Courmont  and  Rollet,^  of  Lyons,  report  45  cases  of 
corneal  ulceration  as  occurring  in  641  cases  of  variola.  The 
statistics  of  these  clinicians,  therefore,  show  a  higher  percentage 
of  corneal  complication  than  the  statistics  first  quoted. 

Retinal  hemorrhages  are  frequent  occurrences  in  the  type  of  the 
malady  known  as  variola  hemorrhagica. 

Iritis,  cyclitis,  choroiditis  and  retinitis  are  very  rare,  but  all  have 
been  observed  as  complications  of  variola.  Orbital  cellulitis  is 
occasionally  seen  during  the  disease,  and  particularly  in  the  very 
severe  forms. 

Ear  Complications. — Ear  complications  are  frequent  during 
variola.  The  external  auditory  canal  is  frequently  the  site  of 
variolous  lesions,  and  the  obstruction  of  the  canal  often  causes 
impairment  of  hearing  as  well  as  many  unpleasant  auditory  sensa- 
tions. Among  these  otic  conditions  otitis  media  is  frequent  in 
children,  but  is  less  commonly  observed  in  adults.     In  the  lattei- 

'  Marson.     Quoted  by  Moore  in  Twentieth  Century  Practice  of  Medicine. 
2  Dufour.     Annale?  d'Oculistiques,  May,  1901. 
'  Courmont  and  Rollet.     Ibid. 


UI'ISI'IKATOL'Y    COMI'/JCAf/OXS  300 

class  the  otitis  nifciy  ^ocs  on  lo  .sii[)|)iir;i(ioii,  hut  llic  f((iii|)l;iiiit 
of  earache  is  a  comiiioii  one,  particularly  (liiriii^^  f'Oiivalcsccncc. 
The  condition  is  iisnally  j^roduced  l)y  extension  of  the  infhinnri;ition 
from  the  throat  alonfj;  the  P>u.stachian  tnhc,  or  hy  diicrt  ini'<-ftif»n 
through  this  channel,  in  some  few  cases  (hroniho.^is  ol"  the  cere- 
bral sinuses  hits  followed  otitis  media,  hut  tnastoi<l  siijjjjuration 
during  variola  is  an  infrcfjuent  complication;  the  few  cases  seen 
have  been  mostly  observed  in  cliildicn. 

Facial  paralysis  is  a  complication  rarely  seen,  and  is  doubtless 
due  to  the  extension  of  inflammation  to  the  facial  nerve  as  it  trav- 
erses the  stylomastoid  foramen. 

Respiratory  Complications. — Respiratory  comj)lications  are 
connnon  during  variola.  Because  of  the  severe  lesions  which 
develop  in  the  nasal  and  lower  respiratory  tracts  in  cases  of 
hemorrhagic  smallpox,  epistaxis  and  haemoptysis  may  be  met 
with  in  this  type  of  case  and  occasionally  in  less  severe  cases 
that  are  not  hemorrhagic. 

Laryngitis  during  variola  is  a  very  common  symptom,  and  is 
due  in  many  cases  to  the  presence  of  variolous  lesions  on  the  mucous 
membrane  of  the  larynx.  The  onset  of  this  symptom  is  usually 
gradual  and  is  attended  by  hoarseness,  laryngeal  cough,  anrl  often 
by  dyspnoea,  which  not  infrequently  renders  tracheotomy  or  intu- 
bation necessary.  On  the  other  hand,  ulceration  of  the  larynx 
and  oedema  of  the  glottis  very  rarely  occur,  but  when  these  symp- 
toms occur  they  are  extremely  fatal.  Laryngitis  when  it  is  severe 
is  a  grave  complication,  but  in  practically  every  case  of  variola 
a  slight  grade  of  laryngitis  is  present.  Peaudeleu^  has  reported  a 
number  of  cases  with  so  severe  a  laryngitis  that  intubation  or 
tracheotomy  was  necessary. 

Bronchitis  is  another  symptom  as  well  as  a  complication  which 
is  almost  invariably  present  in  variola.  Both  bronchitis  and 
bronchopneumonia  are  frequent  complications  among  children 
suffering  from  smallpox,  and  in  this  class  of  cases  it  is  frequently 
fatal  even  when  the  attack  of  variola  is  apparently  mild. 

Lobar  pneumonia  is  a  much  more  rare  complication  during 
variola  than  would  be  thought  probable  when  we  consider  the 

1  Peaudeleu.     Marseille  med.,  1903.  xl,  121. 


310  VARIOLA 

exhaiisting  nature  of  the  orioinal  disease.  Welch  and  Schamberg^ 
saw  but  one  case  of  this  compHcation  in  over  2000  cases  of  variohi. 
^Yhen  lobar  pneumonia  develops  during  variola  it  usually  occiu's 
as  a  late  sequel  and  is  of  the  nature  of  a  terminal  infection, 
the  resistance  of  the  patient  to  the  pneumococcus  being  greatly 
lowered. 

PleI'RITIS,  on  the  other  hand,  occurs  more  fre(piently  than  would 
be  supposed  from  the  rarity  with  which  pneumonia  is  met  with,  and 
when  pleurisy  develops  it  is  not  rarely  followed  by  empyema. 

Hydrothorax,  due  to  a  complicating  nephritis  or  to  a  failing 
heart,  or  both,  is  by  no  means  rare,  and  as  pleural  effusions  are 
often  insidious  in  their  development,  it  is  advisable  to  frequently 
examine  the  chest  of  the  patient  during  the  coinvse  of  the  disease. 

The  Digestive  System. — The  digestive  system  is  not  greatly 
affected  in  variola,  although  troublesome  symptoms  referable  to 
some  part  of  this  tract  are  frequently  met  with. 

Ulcerative  stomatitis  is  occasionally  seen,  and  much  less  fre- 
quently gangrenous  stomatitis  or  noma  is  met  with.  In  Tourdes'^ 
analysis  of  98  cases  of  noma,  five  were  found  to  have  complicated 
variola,  and  Dexeus^  has  reported  a  case  occurring  as  a  sequel 
to  smallpox. 

Glossitis,  of  varying  degrees  of  severity,  occurs  in  the  vesicular 
and  pustular  stages.  When  the  glossitis  is  severe,  the  tongue  is 
enormously  swollen,  filling  the  cavity  of  the  mouth  and  often  pro- 
truding between  the  teeth  and  lips,  thus  preventing  the  patients 
taking  nourishment.  WTien  this  complication  is  very  severe  it  is 
often  fatal. 

Parotitis,  unilateral  or  bilateral,  is  an  uncommon  complication, 
but  occurs  in  a  few  of  the  more  severe  cases.  Unfortunately  the 
records  concerning  these  complications  of  the  disease  are  so  in- 
complete that  we  cannot  present  actual  percentages  of  their  occur- 
rence. On  the  other  hand,  ulceration  of  the  palate,  fauces,  and 
pharynx  is  frequendy  observed  in  severe  confluent  cases.  The 
fauces  or  tonsils,  or  both,  may  be  covered  with  a  dirty  membrane 

'  Welcli  and  Sfliamberg.     Acute  Contagious  Diseases,  p.  236. 

-  Tourdes.     Tliese  de  Strassburg,  1898. 

'  Dexeus.     Med.  de  las.  nifios,  Bareel.,  1905-190C,  p.  14]. 


Till':  iih'Airr  diuung  vaiuola  .     'M\ 

resembliii<i,'  IIimI  oI'  dipliilnTi;!,  l>iii  Inir^  (|i|)litlicii;i  i^  |)i-;ifii'-;illy 
iitiknowii  ill  (mliiiiiiy  cases  <)!'  variohi.  An  onliiuirv  ih-f^'n-c  r>j' 
pliaryii^'itis  is  very  common  in  all  forms  of  variola,  and  partir  iihirly 
so  in  the  severe  attacks.  Postpharyngeal  abscess  is  a  rare  rjffiir- 
rence. 

Thyroid itia  durhnj  smallpox  is  not  nearly  as  rare  as  tfic  laf;k  oi 
literature  upon  the  subject  would  lead  one  to  believe.  Roger  and 
Gamier^  have  reported  several  cases,  and  one  of  ns  u  lillc  an  interne 
at  the  Municipal  ITos})ital  saw  this  complication  several  times 
among  the  female  patients,  and  once  it  occurred  in  a  young  man, 
who  suffered  from  a  malignant  attack  of  variohi,  wliieii  proved 
ra])idly  fatal. 

The  Heart  during  Variola. — The  heart  during  variola  suffers 
the  changes  that  attend  any  acute  febrile  infection,  and  because 
of  the  severity  of  the  disease  it  is  but  natural  that  we  should 
expect  to  find  degenerative  changes  taking  place  in  the  heart 
muscle.  It  is  surprising  how  little  literature  there  is  upon  changes 
in  the  heart  and  bloodvessels  during  variola,  and  investigations 
are  sadly  needed  along  this  line.  Myocarditis  is  certainly  present 
in  a  very  large  number  of  the  severe  cases  of  the  disease,  and  deaths 
from  acute  dilatation  of  the  heart  are  occasionally  seen. 

Pericarditis  and  endocarditis  are  infrequently  reported  as  having 
complicated  variola.  Cardiac  murmurs  are  of  frequent  occurrence 
at  the  height  of  the  disease,  especially  those  which  are  heard  in  the 
region  of  the  apex,  but  they  are  apparently  due  to  relaxation  of  the 
heart  muscle.  One  of  us  examined  six  cases  at  autopsy  which 
during  life  had  shown  murmurs,  but  no  lesion  of  the  valves  was 
discovered.  Curschmann"  reports  having  seen  a  case  of  ulcerative 
endocarditis  complicating  a  confluent  case  of  variola,  but  states 
that  endocarditis  during  this  disease  is  rare.  Welch  and  Scham- 
berg'  are  of  the  opinion  that  endocarditis  is  very  rare  in  this 
disease. 

Phlebitis  is  occasionally  met  with  during  the  period  of  con- 
valescence. 

1  Roger  and  Gamier.  Presse  Med.,  Paris,  1903,  i,  37.3. 
-  Cursclimann.  Nothnagel's  System  of  Medicine.  Variola. 
5  Welch  and  Scliamherg.     Acute  Contagious  Diseases,  p.  236. 


312  VARIOLA 

Abdominal  Complications. — Abdominal  complications  are  rare 
in  variola,  and  peritonitis  is  very  uncommon.  ]MacComl)ie*  has 
reporteil  two  cases  of  peritonitis  tluring  variola;  one  was  asso- 
ciated with  pleurisy,  the  other  a  local  peritonitis,  but  in  neither 
instance  is  any  statement  made  as  to  the  cause  of  the  infection. 
MacCombie  has  also  reported  two  cases  of  peritonitis  following 
abortion  during  variola. 

Abscesses  in  the  liver  and  kidneys  have  been  reported  as  occurring 
during  the  course  of  the  disease,  but  are  very  rare,  and  infarcts 
have  been  found  in  both  the  spleen  and  kidney  in  certain  fatal 
cases. 

Joint  Complications  during  Variola. — Joint  complications 
during  variola  are  sometimes  met  with,  and  are  also  occasionally 
observed  as  sequels  of  this  disease.  These  complications  are  most 
often  noted  among  children,  and  usually  one  or  more  joints  are 
involved.  The  ell)ow  appears  to  be  the  joint  most  commonly 
affected,  although  the  wrist  is  also  a  favorite  place  for  this  com- 
plication to  show  itself. 

Chondritis,  osteitis,  and  osteomyelitis  are  all  rare  complications, 
but  all  may  occur  as  secjuels  to  variola.  Voituriez,^  Debryre,* 
and  Ingelraus^  have  all  reported  bone  complications  and  sequels 
to  this  disease. 

Genito-urinary  Complications. — Genito-urinary  complications 
during  variola  are  frequently  met  with.  Phimosis  is  not  infre- 
quently met  with  in  the  pustular  stage,  and  is  the  result  of  the 
sw'elling  of  the  tissues  of  the  prepuce  caused  by  the  presence  of  the 
rash.  This  complication  is  met  with  among  children  most  fre- 
quently, in  whom  it  often  causes  retention  of  urine.  Adult  patients 
often  complain  of  great  pain  on  urination,  partly,  no  doubt,  because 
of  the  highly  acid  condition  of  the  urine  and  partly  because  of  the 
presence  of  variolous  lesions  within  the  urethra. 

Albuminuria  and  nephritis  during  variola  are  frequently 
developed.  Albuminuria  is  frequent  in  both  the  mild  and  the 
severe  form  of  the  disease.     Welch  and  Schamberg"   found  that 

1  MacCombie.      In  System  of  Medicine,  by  Allbutt  and  Rolleston,  Variola,  p.  514. 

2  Voituriez.     Jour,  de  Sci.  Med.,  Lille.  190.3,  xxiii,  93. 

3  Debryre.     Echo  M^d.  du  Nord.,  Lille,  1903.  *  Ingelraus.     Ibid. 
'  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  236. 


PREGNANCY  COMPIJCATING  VAUfOLA  :',]:', 

663  per  cent,  of  their  cases  of  variola  had  antuniiii  in  lh<-  nriiio 
diirui*!;  the  course  ol"  th(!  disease,  and  (iO  pci-  ccnl.  of  Hn-  cases 
of  variohjid  liad  albuininiiria.  It  is  siirprisiiin;  (o  noic  (hat  in 
50  per  cent,  of  the  cases  of  varioloid  die  urine  conlaitied  tube 
casts,  but  of  the  cases  of  variola  only  42  per  cent,  contained  casts. 
The  comparative  fref(uency  of  })oth  albumin  and  casts  in  fatal 
cases  as  compared  with  those  that  reef)ver('d  may  be  seen  froui  th<; 
following  figures  given  by  Welch  and  Scliambcri^-.  Of  '.'>H  cases  of 
fatal  variola,  30,  or  S4.47  per  cent.,  showed  albuminuria,  and  10, 
or  50  per  cent.,  showed  casts.  Of  90  cases  that  recovered,  45,  or  50 
per  cent.,  had  albumin  in  the  urine,  and  41,  or 45.55  percent.,  .showed 
casts.  It  was  noted  in  this  series  of  cases  that  when  albumin  was 
found  in  the  urine  it  usually  appeared  early,  as  did  also  tube  casts. 

ArnamP  examined  the  urine  of  400  cases  of  variola,  and  found 
that  95.3  per  cent,  revealed  albuminuria.  This  same  writer  states 
that  albuminuria  persisted  after  convalescence  in  75  per  cent,  of 
his  cases.  He  believes  that  variolous  albuminurias,  as  in  the  albu- 
minurias accompanying  other  infectious  diseases,  are  not  simply 
functional,  but  are  related  to  a  structural  alteration  in  the  kidneys. 
In  proof  of  this  he  mentions  the  results  of  the  histological  examina- 
tion of  the  kidney,  in  15  cases  of  variola,  in  each  of  which  he  found 
marked  pathological  changes. 

Cystitis  is  rarely  mentioned  as  a  complication  or  sequel  of 
variola,  but  it  is  quite  often  seen  in  very  sick  patients  who  are 
unable  to  void  the  entire  amount  of  urine  in  the  bladder.  This 
complication  usually  occurs  late  in  the  disease  and  recovery  usually 
takes  place  when  the  patient  is  well  of  the  attack. 

Orchitis,  single  or  double,  and  usually  accompanied  by  an  effu- 
sion of  fluid  into  the  tunica  vaginalis,  is  a  rare  complication  of 
variola,  and  usually  occurs  during  the  pustular  stage  of  severe 
attacks  of  the  disease.  Welch  and  Schamberg"  observed  this  com- 
plication but  8  times  in' 2000  cases  of  variola. 

Pregnancy  Complicating  Variola.— Pregnancy  complicating 
variola  is  alwavs  extremelv  dano-erous  for  the  unborn  child  and 
adds  greatly  to  the  danger  of  the  mother.      The  function  of  the 

1  Arnaud.     Revue  de  M^decine,  1S9S.  xviii.  392. 
"  Welch  and  Schamberg.     Loc.  cit.,  p.  237. 


314  YAJ^IOLA 

pregnant  uterus  is  greatly  disturWcd  duriiio-  (he  coiu'se  of  variola, 
and  abortions  and  miscarriages  are  common.  In  a  series  of  113 
cases  of  variola  in  pregnant  women,  treated  at  the  iNIunicipal 
Hospital  of  Philadelphia,  35  died,  giving  a  mortality  rate  of  about 
31  per  cent.,  and  in  '27  unvaccinated  pregnant  patients,  20,  or  74 
per  cent.,  died.  Of  85  pregnant  women  vaccinated  at  an  early 
period  in  life,  14,  or  16  per  cent.,  died,  emphasizing  the  fact  when 
abortion  or  miscarriage  occurs  during  variola  it  is  a  much  more 
serious  complication  than  when  it  occurs  during  an  attack  of 
varioloid. 

The  time  at  which  miscarriage  most  frequently  occiu's  is  during 
the  eruptive  stage  of  the  disease,  but  it  may  occur  at  any  time, 
even  after  complete  restoration  to  health. 

If  the  mother  goes  to  term,  the  child  is  to  some  extent  protected 
from  the  disease,  although  eases  are  on  record  in  which  children 
have  had  smallpox  before  birth,  and,  extraordinary  to  relate,  there 
are  instances  reported  in  which  the  newborn  child  bore  the  eruption 
of  variola  at  birth  despite  the  fact  that  the  mother  had  not  suffered 
from  the  disease. 

The  Nervous  System. — The  nervous  system  is  more  often 
involved  in  smallpox  than  in  any  of  the  other  eruptive  diseases. 
The  nervous  manifestations  may  appear  during  any  stage,  and 
may  originate  in  the  brain,  in  the  spinal  cortl,  or  in  the  peripheral 
nerves. 

Delirium  during  the  initial  stage  is  common  in  variola,  and  is 
sometimes  seen  in  even  mild  cases  of  varioloid.  This  symptom 
may  abate  when  the  eruption  appears,  but  in  some  instances  it 
merges  into  acute  mania.  MacCombie^  reports  an  instance  of  this 
kind.  In  some  cases  of  variola  which  early  exhibit  marked  men- 
tal disturbances  there  is  a  remission  diu'ing  the  vesicular  stage, 
with  an  exacerbation  of  the  mental  symptoms  when  pustulation 
begins.  In  the  hemorrhagic  form  of  the  disease  the  delirium  is 
often  marked  from  the  beginning  and  continues  until  the  death 
of  the  patient.  In  children  convulsions  are  common  at  the  onset 
of  the  illness  and  mav  occur  during  its  later  stages. 

1  MacCombie.     Loc.  cit.,  p.  51G. 


77/ A'  N/':inr)(/s  systicm  :',]r, 

CoNViTf.SfONS  (liii'iiii;'  (lie  iiiiliiil  st;i<^<'  ol'  ihf  iliscjisfr  arc  alsrj 
occasioiuilly  noted  in  adult  palicnls,  l)iil  lli<'>c  air  usually  .seen  in 
malignant  heinorrlianic  cases. 

Coma  of  varyin<(  intensity  may  he  assoeialcd  uidi  patalysis  niorf; 
or  less  generalized.  Tlic  coma  usually  disappear^  dniin;:  the 
vesicular  stage,  hut  the  j)aralysis  may  persist  foi'  a  long  pcriofl. 

MKLANCiior>iA  is  also  noted  not  int're(|ucnfly  during  convales- 
cence, hut  this  symptom  is  scarcely  ever  ol'  long  duration,  hut  is 
often  a  trouhlesome  sequel.  Strangely  enough,  acute  mania  more 
frequently  complicates  mild  attacks  than  severe  attacks,  although 
it  complicates  hoth,  and  may  appear  at  any  time,  even  late  in  con- 
valescence. Some  patients  so  affected  recover,  hut  others  remain 
permanendy  insane,  although  it  is  common  to  find,  in  those  who 
remain  permanently  insane,  a  family  history  of  mental  derangement. 

Corlett^  reports  a  case  of  acute  mania  which  occurred  on  the 
fourth  day  of  a  discrete  form  of  variola  and  continued  until  the 
death  of  the  patient  six  days  later.  Trousseau,^  Seppilli  and  Mara- 
gliano,^  Welch  and  Schamberg,^  and  others  have  recorded  similar 
cases,  both  in  modified  and  unmodified  cases  of  smallpox. 

The  post-febrile  insanities  are  sometimes  associated  with  par- 
alyses of  various  sorts,  either  local  or  general. 

Paralyses  may  develop  during  the  course  of  variola  without 
being  associated  with  mental  symptoms,  but  aphasia  is  a  frequent 
symptom.  Of  3000  cases  of  variola  studied  by  Welch  and  Scham- 
berg  at  the  Municipal  Hospital  of  Philadelphia,  there  were  recorded 
only  eight  instances  of  paralysis,  but  it  scarcely  seems  possible 
that  all  the  cases  that  suffered  paralysis  were  recorded.  Of  the 
recorded  cases,  five  died  and  three  recovered. 

Hemiplegia  is  occasionally  seen  during  smallpox,  and  has  been 
recorded  more  often  among;  children  than  among  adults.  This 
complication  may  result  from  a  cerebral  hemorrhage,  which  is 
the  most  common  cause,  or  may  result  from  a  thrombosis  of  the 
cerebral  vessels. 

Welch  and  Schamberg  only  record  having  seen  one  case,  and 
that  was  in  an  infant,  aged  one  year  and  four  months. 

1  Corlett.     The  Exanthemata,  p.  66.  -  Trousseau.     Clinical  Medicine.  1S73. 

^  Seppilli  and  Maragliano.     Delia  Influenza  del  Vajuolo  .sulla  Pazzia,  Milan,  1S7S. 
*  Welch  and  Schamberg.     Loc.  cit.,  pp.  237,  23S. 


316  VARIOLA 

Paraplegia  is  more  frequently  met  with  in  varit)la  than  is  hemi- 
plegia, and  is  a  most  serious  and  generally  a  fatal  symptom.  Welch 
and  Schambere;^  have  seen  "  half  a  dozen  or  more  instances."  liu- 
chard"  reported  10  instances  of  paraplegia  occurring  in  2000  cases 
of  smallpox,  and  Spiller'  has  recorded  two  cases.  Westphal'*  has 
reported  cases  of  smallpox  during  which  disease  there  was  marked 
paralysis  of  the  lower  extremities  and  bladder  which  he  believed 
were  due  to  myelitis,  and  Fiessinger^  also  saw  a  case  of  variola 
that  w^as  complicated  with  an  acute  myelitis  during  the  eruptive 
stage  of  the  disease.  xVldrich"  has  recorded  15  instances  of  dis- 
seminated  encephalomyelitis  as  complicating  variola.  He  states 
that  these  cases  improved  rapidly  following  convalescence  from 
the  primary  disease. 

]\Iarinesco  and  Oettinger^  have  seen  a  case  of  acute  ascending 
paralysis  during  variola,  and  this  complication  has  been  noted  by  a 
few  other  observers,  all  of  whom  state  that  the  condition  is  a  very 
fatal  one.  Sottas^  has  reported  a  case  of  disseminated  sclerosis 
in  a  youth,  aged  eighteen  years,  following  an  attack  of  smallpox. 

Peripheral  neuritis  occurs  Avith  greater  frequency  than  has  been 
thought.  Postvariolous  paralysis  of  the  soft  palate  and  structures 
of  the  pharynx  quite  similar  to  those  found  following  diphtheria 
have  been  studied  by  Curschmann,''  Arnaud,^"  Saint-Phillippe,^^ 
Whipham  and  Meyers,^^  and  other  observers.  In  addition  to  these 
cases  of  more  or  less  generalized  paralysis,  we  also  find  cases  of 
local  paralysis,  as  in  the  case  reported  by  Putnam,^^  in  which 
there  was  a  paralysis  of  the  serratus  magnus  muscle,  and  Cursch- 
mann  reports  a  similar  case  of  paralysis  of  the  deltoid  muscle 
during  this  disease. 

1  Welch  and  Schamberg.     Loc  cit.,  p.  239.  -  Huchard.     Quoted  by  Corlett,  p.  66. 

'  Spiller.     Brain,  London,  1803  (with  review  of  the  literature). 

■•  W^estphal.     Berliner  klin.  Wochensehrift,  1872. 

5  Fiessinger.     Mt'd.  Modern  CParis,  1898),  No  9,  p.  341. 

"  Aldrich.     American  .Journal  of  the  Medical  Sciences,  February,  1901. 

^  Marinesco  and  Gettinger. 

8  Sottas.     Gaz.  des.  Hop.,  .\pril  2,  1892,  pp.  405  et  seq. 

'  Curschmann.     Cong,  fiir  innere  Med.,  1886,  Weisbaden,  p.  469. 
1°  Arnaud.     Marseille  Med.,  1896,  xxxiii,  129  to  140. 
"  Sai.t-Phillippe.     Quoted  by  Combemole,  .A.rch   de  mdd.,  .June,  1892. 
1=  Whipham  and  Meyers.     Lancet,  March  20,  1886. 
'^  Putnam.     Boston  Med.  ..nd  .Surg.  Jour.,  Ixxxix,  12.5. 


CHAPTER    IT. 

SCARLET  FEVER. 

ALTHOUGn,  as  a  result  of  the  improvement  of  tlie  laws  coneerning 
sanitation  and  the  general  advance  toward  better  hygiene  in  liomes, 
schools,  and  hospitals,  there  has  been  a  marked  decrease  in  the 
morbidity  as  well  as  the  mortality  of  scarlet  fever,  nevertheless  this 
disease  and  its  complications  and  sequels  are  of  great  interest 
and  importance.  The  death-rate  of  scarlet  fever  in  the  United 
States  is  slightly  higher  than  that  of  measles,  and  averages  about  the 
same  as  the  death-rate  of  scarlet  fever  in  Great  Britain.  Although 
the  morbidity  and  mortality  have  been  greatly  reduced  in  recent 
years,  they  still  are  subject  to  much  variation  in  different  periods. 
The  annual  average  death-rate  for  the  years  1901  to  1905  inclusive 
was  11.1  per  100,000.  Of  26,921  cases  of  scarlet  fever,  3216,  or 
11.9  per  cent.,  were  fatal.  Holt  states  that  the  average  mortality 
is  from  10  to  14  per  cent.,  but  that  children  under  five  years  of 
age  the  mortality  varies  from  20  to  30  per  cent. 

In  scarlet  fever  the  complications  and  sequels  are  more 
important  and  numerous  than  in  any  other  of  the  infectious 
eruptive  diseases.  It  has  been  well  said  by  William  Pepper  that 
this  disease  "maimed  when  it  did  not  kill,"  thus  calling  attention 
to  the  tendency  of  many  of  its  complications  to  become  chronic, 
and,  when  neglected,  to  lead  to  loss  of  the  functions  of  certain 
organs,  or,  in  some  instances,  to  permanent  impairment  of  health. 
Scarlet  fever,  therefore,  depends  very  largely  for  its  gravity,  and 
for  the  fear  it  causes  in  the  home  and  the  community,  upon  the 
severity  and  the  danger  of  its  complications  and  sequels. 

The  common  comphcations  of  scarlet  fever  are:  Rliinorrhoea, 
otitis,  ulcerative  stomatitis,  tonsillitis,  adenitis,  scarlatinal  synovitis 
(scarlatinal  rheumatism),  neplu'itis,  with  ulcerative  and  gangrenous 
angina,  bronchopneumonia,  and  ocular  complications. 


318  SCARLET  FKVER 

Before  taking  up  the  various  C()inj)Iic'ati()iis,  it  will  be  well  to 
consider  the  initial  or  premonitory  rashes  as  well  as  the  various 
skin  manifestations  ()i)served  during  the  disease. 

Premonitory  Rashes. — Premonitory  rashes  are  fairly  frequently 
seen  early  in  this  disease,  and  they  are  of  great  importance 
from  a  diagnostic  standpoint.  Scarlatiniform  rashes  of  varying 
degrees  of  intensity  are  common,  and  their  differentiation  from  the 
eruption  of  other  diseases,  as  well  as  from  the  true  eruption  of 
scarlet  fever,  is  often  not  readily  made.  It  is  in  the  mild  or  atypical 
cases  of  scarlet  fever  that  mistakes  often  take  place,  and  in  these 
cases  it  is  only  after  a  careful  study  of  the  history  of  the  illness,  the 
symptoms,  and  the  rash  that  an  opinion  of  value  can  be  rendered. 

Unfortunately,  despite  the  greatest  care,  in  c|uite  a  large  propor- 
tion of  cases  the  true  diagnosis  is  only  revealed  when  desquama- 
tion appears  or  when  some  typical  complication  develops,  which 
proves  that  the  primary  disease  w^as  true  scarlet  fever. 

Helpful  points  in  determining  that  the  eruption  is  that  of  scarlet 
fever  have  been  pointed  out  by  WhitfiekP  as  follow^s:  (1)  The 
rash  in  scarlet  fever  always  appears  first  at  the  root  of  the  neck; 
(2)  when  not  absolutely  universal  the  edge  of  the  eruption  gradu- 
ally fades  off  into  normal  skin  and  the  tip  of  the  nose  and  the 
circumorbitaal  region  is  never  affected ;  (3)  a  yellowish  stain  appears 
w^hen  the  hypersemia  is  displaced  by  pressure  on  the  skin,  and 
browning  of  the  flexures  of  the  elbow's  is  almost  invariably  present; 
(4)  the  backs  of  the  hands  and  the  sides  of  the  fingers  are  generally 
affected  when  the  rash  is  fully  developed. 

Miliary  vesicles  are  seen  in  nearly  all  pronounced  cases  of  scarlet 
fever,  but  in  the  skin  of  some  persons  this  variety  of  eruption  is 
much  more  in  evidence  than  in  that  of  others.  Griffith^  has 
reported  several  marked  instances  of  this  eruption,  and  gives  it  the 
name  of  "scarlatina  miliaris." 

Febrile  herpes  is  an  unusual  complication  of  scarlet  fever,  but 
is  more  frequent  in  this  disease  than  in  smallpox  or  measles. 

Urticaria  is  occasionally  seen  during  an  attack  of  scarlet  fever, 
and  this  rash  is  usually  in  evidence  before  the  true  scarlet  rash 

'  W'hit field.     The  Practitioner,  January,  1909,  p.  69. 

-  Griffith.     Scarlatina  Miliaris,  Jacobi's  Festschrift,  1900,  pp.  182  to  186, 


uiiiNOiaaKi'iA  319 

appears,  ("onion'  rcporls  ;i,  r'ji.sc  in  wliicli  nitifji  il;i  f  (ini|ili';in-(| 
tlic  ousel,  of  sciirlcl,  fever,  iUid  was  in  evidence  for  several  days. 

Blebs  and  Bullae.  IJlehs  and  hnlla-  may  develf>fj  (\\\v\u[r  the 
course  of  llie  disease,  l)ii(  aic  nnnsnal.  When  llie\  oecni-  llievare 
usually  seen  in  very  severe  eases,  and  sonielimes  le;id  Wi  ;ian;.Tene 
of  tlic  skin. 

Gangrene  of  the  Skin. — Gangrene  of  die  skin  is  sometimps 
seen  during  scarlet  fever  in  eliildren  wlio  are  li\in;^'  in  erovMJefl 
quarters,  and  the  term  "derniatitis  gaiigra-nosa,"  or  "scarlatina 
gangra^iosa,"  has  been  aj)plied  to  such  cases,  '^l^his  complication 
usually  appears  at  the  height  of  the  disease,  hnl  i(  may  aj)j)ear,  as 
in  a  case  reported  by  ITeubner,^  as  late  as  one  month  after  convales- 
cence. Gangrene  of  other  portions  of  the  body  are  observed  during 
scarlet  fever  in  rare  instances.  This  condition  usually  develops 
during  the  second  or  third  week  of  the  disease  in  severe  cases, 
and  usually  attacks  the  extremities.  The  condition  is  usually 
attributed  to  embolism  of  the  dermal  vessels.  Cases  of  this  kind 
have  been  reported  by  many  observers,  among  them  Blandpain,^ 
Hudson,^  Kuster,^  Chapin,"  Eichhorst,^  Pearson  and  Littlewood,* 
Buchan,^  and  Welch  and  Schamberg,^"  Wood  and  Arrigone"  have 
reported  cases  of  gangrene  affecting  the  genitals,  and  Wilson'^  a 
case  of  gangrene  of  the  face  three  weeks  after  convalescence  from 
scarlet  fever. 

Rhinorrhoea. — Rhinorrhoea  is  a  very  frequent  symptom  of  all 
attacks  of  scarlet  fever,  but  it  is  particularly  in  evidence  in  the 
severe  forms.  It  appears  in  two  forms.  In  the  first  the  dis- 
charge from  the  nose  is  purely  mucous  in  character,  similar  to  the 
discharge  seen  in  a  case  suffering  from  a  catarrhal  cold.  In  the 
second  form  the  discharge  is  mucopurulent,  and,  especially  if  thin 

1  Coulton.     La  M^decine  Infantile,  Paris,  February  15,  1894. 

2  Heubner.     Medical  Press,  September  30,  190S. 

3  Blandpain.     Arch.  Med.  Beiges,  Brux.,  1S69,  ii,  324  to  331. 
1  Hudson.     Trans,  of  the  Ohio  Med.  Soc,  1858- 

6  Kuster.     Tod  Kassel,  1876-1878. 

15  Chapin.     Medical  Age,  Detroit,  1884. 

'  Eichhorst.     Deut.  Arcliiv  fur  klinische  Med.,  Band  Ixx,  Heft  5. 

s  Pearson  and  Littlewood.     Dry  Gangrene  of  both  Legs,  Lancet,  1897,  ii,  84 

8  Buchan.     Lancet,  October  5,  1901,  p.  915. 

10  Welch  and  Scbamberg.     Acute  Contagious  Diseases,  p.  423. 

11  Wood  and  Arrigone.     Quoted  by  Thomas,  Ziemssen's  Encycloptedia,  p.  190. 
1=  Wilson.  _  Article  reviewed  in  Arehiv  f.  Kinderheilk,  1898,  p.  418. 


320  SCARLET  FEVER 

anil  straw-colored,  is  the  result  of  a  destructive  ulceration  of  the 
posterior  nasal  mucous  membrane.  French  writers  assert  that 
early  purulent  corvza  is  of  evil  significance  in  scarlet  fever.  Thus 
ill  one  epidemic  in  the  Arbervillier  Hospital  the  mortality  of  these 
cases  was  over  50  per  cent. 

Not  only  is  a  purulent  rhinorrhoea  dangerous  in  the  acute 
stage,  but  in  the  cases  which  recover  the  rhinorrhoea  is  apt  to 
become  clironic  and  does  not  yield  readily  to  medical  treatment. 
In  many  of  these  cases  the  continued  discharge  is  the  result  of  the 
presence  of  adenoids.  This  complication  is  of  great  importance, 
as  it  bears  a  very  definite  relationship  to  protracted  infectivity  and 
the  spreading  of  the  scarlatinal  infection. 

Otitis  Media. — Inflammation  of  the  middle  ear  is  the  most 
common,  if  not  the  most  dangerous,  complication  of  scarlet  fever. 
It  may  arise  at  any  stage  of  the  scarlatinal  attack.  The  frequency 
of  this  complication  varies  with  the  character  of  the  epidemic  and 
the  age  of  the  patient.  In  the  severe  anginose  attacks  of  the  disease 
middle-ear  complications  follow  nearly  every  case.  Infants  seem 
more  liable  to  develop  otitis  media  than  do  children  who  are  a 
little  older.  This  is  possibly  accounted  for  by  the  relatively  large 
Eustachian  tube  in  infancy.  The  otitis  may  occur  either  in  the 
form  of  a  simple  inflammation  of  the  external  auditory  canal,  with 
possibly  a  slight  involvement  of  the  membrana  tympani,  in  wliich 
case  it  is  a  trivial  aflfection  of  short  duration,  or,  as  is  much  more 
common,  in  the  form  of  an  otitis  media  followed  by  more  or  less 
profuse  mucopurulent  discharge. 

Caiger^  states  that  15  per  cent,  of  10,983  cases  of  scarlet  fever 
developed  otitis  media.  Bader  and  Geuinon"  report  33  per  cent, 
involvement  in  the  mild  catarrhal  form,  and  purulent  otitis  media 
in  but  4  or  5  per  cent,  of  scarlet  fever  cases.  Sprague^  states 
that  from  3  to  9  per  cent,  of  children  suffering  from  scarlet  fever 
develop  ear  complications,  and  in  50  per  cent,  of  these  both  ears 
are  involved. 

Bezold,^  of  Munich,  found  that  37.5  per  cent,  of  1787  cases  of 

1  Caiger.     In  System  of  Medicine  by  Allbutt  and  Rolleston,  vol.  iii,  p.  150. 

2  Bader  and  Geuinon.     See  Moizart  in  Trait<?  des  mal.  de  I'enfant,  1897,  vol.  i. 
'  Sprague.     American  Journal  of  the  Medical  Sciences,  September,  1905. 

*  Bezold.     Zeitsch.  f.  Ohrenheilk.,  xxiii,  70-73. 


MASTOIJj/r/S  321 

Sfarlet  fever  rlevelojx'd  ciir  f()iii[)lie;ili()iis.  Of  these  040  eases 
with  ear  comph'ead'oii.s,  y>u.'>  h;i(l  chronif;  sii|)piir;ifif)ri  hislinrr  ff)r 
over  eight  years. 

The  annual  report  of  tiie  Metropolitan  Asylum's  lioard  ff>r  KiOG 
states  that  2355  eases  of  searlet  fever  fiiul  r)fi(is  in  ]7,'S20  eases 
(13.21   per  eent.). 

ill  Ihe  1007  rej)()rl  of  the  same  hojinl  the  percentage  of  ear 
(•ompiieations  is  given  at  11.4  per  eent.  Biirekhanlt-Merian' 
found  that  of  4309  cases  of  otitis  media,  445,  or  lO:}  per  cent.,  were 
due  to  scarlet  fever.  At  the  Willard  Parker  Hospital,  in  1898,  of 
386  cases  of  scarlet  fever,  otitis  occurred  in  77  eases,  33  of  which 
were  affected  in  both  ears. 

Le  Marc'hadour"  foimd  30  instances  of  otitis  in  339  cases  of 
scarlet  fever  (10.65  per  cent.). 

MacCrae^  stated  that  of  325  cases  of  scarlet  fever  under  his  care, 
83,  or  25.5  per  cent.,  developed  otitis  media.  Fifty-seven  of  this 
last  series  were  suppurative  cases  (17.5  per  cent.). 

Purulent  otitis  media  usually  pursues  a  protracted  course,  and 
frequently  lasting  for  years,  often  for  a  lifetime.  The  dangers, 
immediate  and  remote,  from  this  condition  are  many,  the  chief 
one  being  the  danger  of  extension  of  the  purulent  process  to  the 
mastoid  cells  or  to  the  coverings  of  the  brain,  while  the  less  frequent 
but  more  immediately  fatal  complications  are  the  erosions  of  large 
bloodvessels  and  the  development  of  septicaemia  and  pyaemia. 

Baader,  Hynes,^  Hessler,"  Huber,'  and  others^  have  reported 
fatal  instances  of  hemorrhage  due  to  the  erosion  of  the  carotid 
artery  as  a  result  of  the  septic  processes  connected  with  otitis  media. 

The  hemorrhage  in  these  cases  may  pour  from  the  ear  or  cause 
hcTmatoraa  in  the  tissues  of  the  neck. 

Mastoiditis. — Not  infrequently,  within  a  few  weeks  after  the 
appearance  of  an  otorrhoea,  an  inflammatory  swelling  appears  in 
the  mastoid  region  attended  by  severe  pain  and  acute  tenderness 

1  Burckhardt-Merian.     (Volkman's)  Sammlung  klin.  Yortr.,  18S0,  Chirurgie,  Xo.  54. 
-  Le  Marc'hadour      Gaz.  des  Maladies  Infantiles,  Xovember  5,  1903. 
3  MacCrae.     Montreal  Medical  Journal.  September.  1908. 

*  Baader.     Corresbl.  f.  Schweiz  Aerzte,  18~5.  Band  v. 

*  Hynes.      Quoted  by  Forchheimer.     Twentieth  Century  Practice  of  Medicine. 
8  Hessler.     Quoted  by  Forchheimer,  loc.  eit. 

'  Huber.     Deutsche  Archiv  f.  klin.  Med.,  Bd.  viii,  p.  422. 
8  Kennedy,  Moller,  and  West.     Quoted  by  Welch  and  Schamberg. 
21 


322  SCARLET  FEVER 

in  this  region.  Of  the  1650  cases  of  otitis  medio  quoted  hy  Caiger, 
0.6  per  cent,  developeil  a  mastoid  abscess. 

Of  the  17,829  cases  of  scarlet  fever  re})()rt('d  In  tlic  Metropolitan 
Asylum's  Board  for  1006,  2355  were  complii-ated  with  otitis  media 
(13.21  per  cent.),  122  of  which  developed  mastoid  abscess  (0.68  per 
cent.).  The  usual  history  in  a  case  of  mastoiditis  during  scarlet 
fever  is  that  the  patient  has  a  discharging  ear,  but  with  the  establish- 
ment of  communication  between  the  tympanic  cavity  and  the  cells 
of  the  mastoid  there  is  usually  a  decrease  in  the  amount  of  discharge 
from  the  ear.  and  the  temperature  at  once  rises.  There  is  pain 
over  the  mastoid  region  and  tenderness  more  or  less  marked.  It  is 
not  unusual  for  the  patient  to  feel  chilly  or  even  to  have  a  chill, 
and  there  is  commonly  great  discomfort  and  restlessness. 

Meningitis  and  Tempore  sphenoidal  Abscess. — It  has  long 
been  known  that  these  complications,  as  well  as  other  intracranial 
abscesses,  are  all  liable  to  occur  in  cases  of  chronic  middle  ear 
disease,  and  are  particularly  prone  to  occur  in  scarlatinal  cases. 

Purulent  meningitis  is  a  very  serious  complication,  which  may 
arise  from  a  suppurative  otitis  media.  Welch  and  Schamberg^ 
report  such  a  case  in  which  a  child,  aged  three  years,  developed  this 
condition  on  the  fifty-fourth  day  of  the  attack  of  scarlet  fever,  and 
died  ten  days  later.  Autopsy  revealed  a  pm-ulent  exudate  covering 
the  entire  base  of  the  brain. 

Roger^  saw  a  case  in  which  meningitis  followed  a  severe  purulent 
rhinitis  complicating  scarlet  fever.  At  the  autopsy  the  left  frontal 
lobe  was  covered  with  purulent  material  and  the  left  sphenoidal 
sinus  contained  pus. 

Sinus  thrombosis  is  a  rare  complication  which  occurs  as  a 
sequel  to  otitis  media. 

Facial  Paralysis. — Facial  paralysis  is  a  relatively  infre(juent 
complication  of  scarlatinal  otitis,  although  it  has  been  repeatedly 
observed  by  those  seeing  a  large  number  of  suppurative  otitis  cases 
complicating  scarlet  fever.  The  conflition  is  due  to  an  extension 
of  the  inflammation  from  the  tympanum  to  the  facial  nerve  where 
it  passes  through  the  roof  of  the  cavity. 

'  Welch  and  Sehamberg.     Acute  Contagious  Diseases,  pp.  403,404. 
-  Roger.     La  Maladies  Infectieuses  (Meningitis  in  Scarlet  Fever). 


ADI'INITIS  323 

Deaf  Mutism. — Nol,  only  is  otitis  mcdiit  (Vau^cvow  .  \u  life,  \,\\t 
this  coiiipliciilioii  is  rcsfKJiisihIc  for  many  fuses  of  (|(;iF  imiii  m. 

Na^cr'  liiis  ("illcd  |);irlicnl;ir  ;ilfcn(ion  to  the  f;isii;il  rchitioii  liip 
of  j)nriilt'nt  otitis  media,  iiiid  deaf  mutism,  and  states  that  one  ease 
of  deaf  irnitism  occurs  in  (;ach  S(JO  cases  of  srvirlet  fever,  and  May^ 
states  that  10  per  cent,  of  5000  cases  of  dcjif  mutism,  whose  his- 
tories he  investigated,  owed  tiieii"  deafness  to  the  aural  eom|)li';i- 
tions  of  scarlet  fever. 

Wilde,"'  wliose  statistics  coneerninn-  (h-jif  mutism  in  Ih  rchition 
to  scarlet  fever  are  tlie  earliest  known,  states  that  7  [xr  ccuf.  f>f 
the  cases  of  accpiired  deaf  mutism  in  Ireland  in  ISol  were  due  to 
scarlet  fever.  In  (iermany,  Ilartmann*  investigated  this  subject, 
and  found  that  11.3  per  cent,  of  the  cases  of  deaf  mutism  were  due 
to  scarlet  fever.  Other  statistics  state  that  in  Italy  1.5  per  cent., 
Austria  10.8,  Ireland  10.8,  United  States  26.4,  Norway  27.5, 
Saxony  42.6,  and  Denmark  20.8  per  cent,  were  due  to  scarlet 
fever. 

From  these  figures  it  can  be  seen  that  scarlet  fever  gives  rise  to 
acquired  deaf  mutism  in  from  1.5  to  27.  5  per  cent,  of  cases. 

The  cause  of  deafness  lies  in  the  partial  or  entire  destruction  of 
the  labyrinth  from  middle  ear  suppuration.  It  is  seldom  that 
serious  deafness,  resulting  in  deaf  mutism,  appears  at  an  early 
stage  of  scarlet  fever.  Burckhardt-Merian'  has  shown  that  the 
majority  of  all  cases  occur  during  the  stage  of  desquamation. 

Adenitis,  or  a  generalized  enlargement  of  the  lymph  glands, 
constitutes  a  part  of  the  normal  symptomatology  of  scarlet  fever. 
It  is  only  when  the  lymph  glands  become  excessively  enlarged  or 
undergo  suppuration  that  a  complication  is  added  that  increases 
the  danger  of  the  disease.  Adenitis  of  a  marked  degree  is  verv 
common  in  this  disease,  is  quite  distinct  from  the  glandular 
swelling  of  onset,  and  may  vary  from  a  slight  glandular  fulness 
to  a  very  severe  glandular  infiltration  with  enormous  swelling  of 
the  neck,  the  so-called  "collar  of  bra'uni"  or  "tippet  neck."    The 

J  Nager.     Corresbl.  f.  Schweiz  Aerzte,  September  15,  p.  592. 

-  May.     Archives  of  Pediatrics,  July,  1S99. 

'  Wilde.     Quoted  by  Yearsley,  Practitioner,  January,  1909,  p.  36. 

■*  Hartmann.     Taubstummheit  und  Taubstuninienbildung,  Stuttgart,  18S0 

^  Burckhardt-Merian.     (Volkman's)  Sammlung  klin.  Vortr.,  ISSC,  Chirurgie,  Xo.  54. 


324  SCARLET  FEVER 

glaiulular  inflainniatioii  is  jiractically  always  accompanied  l)v 
fever. 

Ludwig's  angina  is  ilu'  naine  given  to  the  most  aggravated 
cases  of  lymphadenitis  which  occur  in  association  with  the  anginose 
variety  of  scarlet  fever.  The  connective  tissue  of  the  neck  may 
become  the  seat  of  a  diffuse  cellulitis  during  the  first  and  second 
week  of  the  disease.  This  condition  is  fortunately  rare,  for  it  is 
almost  invariably  fatal. 

Scarlatinal  synovitis  or  scarlatinal  rheumatism  is  of  sufficient 
intensity  to  give  rise  to  temperature,  pain,  tenderness,  and  distinct 
effusion  into  the  joints,  and  is  a  fairly  frecjuent  complication  of 
scarlet  fever.  It  usually  affects  the  smaller,  rather  than  the  larger 
joints.  The  metacarpophalangeal,  the  fingers,  the  wrist,  and  the 
elbows  are  the  most  frequently  affected.  This  condition  tlevelops 
more  commonly  in  adults  and  older  children  than  in  the  younger 
ones,  and  seems  to  affect  females  in  a  larger  proportion  than  males. 
This  complication  more  frecpiently  complicates  severe  cases  than 
mild  ones,  although  even  mild  attacks  are  often  associated  with 
very  troublesome  pain  in  the  joints.  In  a  series  of  500  cases  of 
scarlet  fever  reported  by  Ashby^  there  were  but  ten  cases  of  mild 
rheumatic  symptoms  and  only  two  cases  in  wdiich  the  symptoms 
were  severe.  In  3000  cases  of  scarlet  fever  studied  by  Hodger,^ 
only  117  cases,  or  3.2  per  cent.,  were  complicated  by  synovitis. 
Hunter's^  experience  at  the  London  Fever  Hospital  ^vas  that  the 
great  majority  of  the  cases  of  scarlet  fever  that  had  articular  pain 
suffered  a  very  short  time,  and  that  the  pain  w^as  not  severe.  He 
states  that  95  per  cent,  of  his  cases  suffered  little  pain,  and  the  pain 
was  evanescent  in  character.  McCrae*  states  that  arthritis  compli- 
cated 17  of  his  series  of  325  cases  of  scarlet  fever  (5.2  per  cent.). 
The  order  of  frequency  in  which  the  joints  were  affected  in  this  last 
series  of  cases  was  knee,  shoulder,  wrist,  ankles,  elbows,  and  fingers. 
The  vertebral  joints  in  the  cervical  region  w^re  affected  twice  and 
in  the  lumbar  region  once.     Carslaw^  (Glasgow)  states  that  60  of  a 

>  Ashby.     Brit.  Med.  Jour.,  1883,  ii,  514. 

-  Hodger.     See  Eichhorst,  Specieile  Pathol()(>:ie  uud  Therapie  (Leipzig,  1897\ 

~  Hunter.     Tiie  Practitioner,  January,  1909   p.  3. 

*  McCrae.     M.jntreal  Medical  Journal,  September,   1908. 

^Carslaw.     Kdinburgh  Medit-al  Journal,  1906,  24,  280. 


hcarIjAtinal  HYNOviris.  on.  nil i:iM.\TisM        :\2') 

series  olT).'}.')  (;iise,s  of  scarlet  !"<•  vet-  uiidcr  liis  f;iic(|(\(|()[>((|  synovitis. 
Ilotno/  in  re})or(in<^  r)0()  cases  of  sfiirld.  U-^-cs,  states  (l];il  I  1,  or  1^.^ 
per  cent.,  developed  arthritis. 

Roberts^  has  reported  the  case  of  a  ^n'rl,  ag(.-d  fifteen  years,  who 
during  an  attack  of  scarlet  fever  developed  pain  and  sweliiiifr  in  ;dl 
the  joints  of  her  horly,  and  later  developed  effusion  into  the  joints, 
but  in  a  few  days  this  coinJition  disappeared.  Detnme,  of  Berne, 
has  reported  a  similar  case. 

Stockman^  tried  an  interesting  experiment  in  five  cases  which 
developed  symptoms  of  arthritis  during  scarlet  fever.  He  gave 
them  no  treatment,  and  found  that  the  symptoms  disappeared  in 
two,  three,  four,  seven,  and  eight  days  respectively.  This  writer 
also  found  that  only  a  very  small  percentage  of  the  cases  of  arthritis 
appearing  during  scarlet  fever  were  relieved  by  the  salicylates, 
and  drew  the  conclusion,  which  is  now  generally  held,  that  scarla- 
tinal arthritis  and  synovitis  is  essentially  a  septic  process  and  has  no 
relation  to  true  articular  rheumatism. 

A  few  of  the  cases  of  arthritis  develop  suppurative  joints.  When 
this  occurs  the  elbow,  wrist,  knee,  and  sternoclavicular  joints 
seem  to  be  the  earliest  involved  and  most  frequently  affected. 
Dr.  Burvill  Holmes  informs  us  that  in  all  the  cases  of  suppurative 
synovitis  coming  under  his  observation  at  the  Municipal  Hospital 
of  Philadelphia,  the  Streptococcus  pyogenes  was  isolated  from  the 
purulent  exudate.  Henoch^  pointed  out  that  the  suppuration  of 
the  joints  might  be  the  result  of  two  processes:  the  first  and  most 
frequent  form  being  that  of  local  development  of  suppuration  in 
the  involved  joint,  or  as  the  result  of  emboli  following  septicaemia 
involving  a  number  of  joints. 

The  most  common  source  of  septicsemia  in  these  cases  is  the 
ulcerative  and  necrotic  processes  in  the  pharynx. 

Bokai^  has  seen  the  local  process  following  a  scarlatinal  arthritis 
become  chronic,  and  instances  of  ankylosis  and  even  deformity  of 
the  joints  have  been  reported  in  the  literatme.*^ 

1  Homo.     Wien.  klin.  Woch.,  1901,  xiv,  281. 

-  Roberts.     Journal  of  the  American  Medical  Association.  July  20,  1907,  p.  246. 

'  Stockman.     Edinburgh  Medical  Journal,  1906,  xx,    244. 

■*  Henoch.     Mittheilungs  ueber  das  Scharlashfieber  und  Vorlesung.  p.  S60. 

^  Bokai.     Ueber  die  Scarlatinossen  Gelenkentzundungen.  Jahr.  f.  Kind.,  1885.  xxiii,  304. 

*  Eichardier  et  Peron.     Soc.  proceed.  Gaz.  des  Hop.,  December  5,  1S93,  p.  1318. 


326  SCARLET  FEVER 

The  prognosis  in  thr  usual  case  of  artluitic  trouble  complicating 
scarlet  fever  is  good,  although  it  is  to  he  remembered  that  the 
presence  of  synovitis  or  arthritis  durino-  scarlet  fever  involves  the 
possible  development  of  endocarditis  and  pericarditis,  as  these 
lesions  are  more  Hkclv  to  occur  in  cases  complicated  In-  joint 
affections,  owing  to  the  septicivmia.    (See  latter  part  of  this  chapter.) 

Vomiting  is  a  frequent  symptom,  and  death  often  results,  although 
this  is  by  no  means  invariable.  Welch  and  Schamberg^  report  a 
case  of  this  complication  occurring  in  a  boy,  aged  thirteen  years, 
who  was  extremely  ill  for  ten  days  with  daily  chills  and  repeated 
vomiting,  but  who  recovered  seventeen  days  from  the  onset  of  the 
complication. 

Nephritis  and  Albuminuria  Complicating  Scarlet  Fever. — 
During  the  febrile  period  of  scarlet  fever,  albuminuria  is  a  very 
common  occurrence.  Roger'  found,  in  his  analysis  of  2157  cases 
of  scarlet  fever  in  adults  and  children,  that  816  cases  show^ed  albu- 
minuria. Of  these  cases,  38.9  per  cent,  were  men,  33.1  per  cent, 
women,  and  24.8  per  cent,  were  children.  It  will  be  seen  from  these 
figures  that  albuminuria  during  the  disease  is  less  frequent  among 
children  than  in  adults.  In  some  cases  the  only  evidence  that  the 
kidneys  are  affected  is  the  presence  of  albumin  in  the  urine, 
although  in  others  the  general  symptoms,  such  as  the  a?dema 
and  the  presence  of  casts  in  the  urine,  render  it  plain  that  a 
true  nephritis  is  present. 

Hunter^  found  that  albumin  occurred  during  the  first  week  in 
scarlet  fever  in  from  36  to  62  per  cent,  of  the  cases.  Of  these,  16  to 
27  per  cent,  showed  albumin  in  the  second  w^eek  and  the  remainder 
in  the  third  and  fourth  weeks.  The  average  of  his  cases  for  the 
years  1905, 1906,  and  1907  in  the  London  Fever  Hospital  shows  that 
43  per  cent,  showed  albumin  during  the  first  week,  18.8  per  cent, 
during  the  second,  11.5  during  the  third,  9.7  during  the  fourth, 
and  8.7  after  the  fourth  w-eek  of  the  disease. 

Febrile  albuminuria  is  usually  slight  in  degree  and  lasts  but  a 
short  time.     Of  Hunter's  149  cases,  in  which  he  records  the  dura- 

'  Welch  and  .Scliamberg.     Acute  Contagious  Disease,  pp.  401,  402. 

-  Roger.     La    Maladies   Infectieuses. 

'  Hunter.     Tlie  Practitioner,  .January,  1909,  p.  3. 


NI<:i'IIIUTI.H  AND   ALIiUMlNUUIA    IN  SCAU/J:'/'   I'HVICH     :>,21 

tion  of  this  syiiiploin,  (iO  sliowcd  ;ill)imiiii  I'lom  oik-  Io  tlii'(-(;  <|;iys; 
20  froin  Tour  to  six  diiys,  niid  20  from  .seven  Io  nine  rlays.  'Jlie 
reiruiindcr  ol"  the  series  showed  itihiiniiri  from  ten  duys  to  two  and 
one-half  months. 

No  separate  line  of  distinction  can  be  drawn  between  albnrninnria 
of  a  severe  degree  and  a  true  nephritis.  In  the  patient  .suffering 
from  a  nephritis,  however,  not  only  does  the  urine  show  consider- 
able quantities  of  albumin  with  many  tube  casts,  but  there  are 
usually  distinct  symptoms  and  signs  that  r(;veal  the  ne[jhritis. 
Not  only  is  there  usually  present  cHstinct  pufHness  of  the  eyeh'ds 
and  fjedema  of  the  extremities,  but  there  is  often  present  a  general 
anasarca.  The  patient  may  suffer  from  pressure  symptoms  be- 
cause of  the  presence  of  fluid  within  the  pleural  sacs  and  peri- 
toneum. Ura^mic  symptoms  are  common,  and  not  infrequently 
cause  death.  In  many  cases  of  nephritis,  however,  recovery  follows 
with  the  subsidence  of  the  primary  disease,  l)ut  unfortunately  the 
patient  is  prone  to  suffer  from  recurrences  of  the  nephritis 
throughout  life. 

It  has  long  been  noted  by  many  observers  that  the  frequency 
of  nephritis  during  scarlet  fever  varies  markedly  in  different 
epidemics.  VogP  reports  as  high  a  percentage  in  one  epidemic 
as  34.  Cadet  de  Grassicourt^  has  observed  late  nephritis  in  30  per 
cent,  of  all  his  cases.  It  v^^as  present  in  18  per  cent,  of  a  series  of 
.  cases  studied  by  Friedlander.^  Baginski^  has  reported  88  cases  of 
nephritis  in  a  series  of  918  cases  of  scarlet  fever,  or  9.57  per  cent. 
Caiger,^  in  reporting  10,983  cases  of  scarlet  fever,  states  that  nephritis 
was  present  in  11.9  per  cent  of  the  cases.  McCrae^  found  albumin 
present  in  18  per  cent,  of  his  325  cases  of  scarlet  fever,  blood  was 
found  39  times,  and  casts  21  times.  He  states  that  in  this  series 
of  cases  only  2.5  per  cent,  showed  nephritis  which  could  \^'ith  truth 
be  said  to  have  resulted  from  the  scarlet  fever.  Hunter's  experi- 
ence in  the  London  Fever  Hospital  was  that  nephritis  was  a  very 

1  Vogl.     Jlunch.  med.  Wocliens  ,  1S95.  p.  949. 

-  Cadet  de  Grassicourt.     Quoted  by  Moizard. 

3  Friedlander.     Fortsch.  der  Med.,  1SS3.  i,  381. 

^  Baginski.     Kinderkrankh.,  Berlin.  1899,  p.  117. 

°  Caiger.     In  System  of  Medicine,  Allbutt's,  New  York,  1897. 

^  McCrae.     Montreal  Medical  Journal,  September,  1908. 


328  SCARLET  FEVER 

variable  complication  both  as  to  degree  and  in  frequency.  It 
occurred  in  but  2.7  per  cent,  of  his  G4S  cases.  Hunter^  found 
that  the  complication  usually  occurred  between  the  eighteenth 
and  thirty-eighth  days  of  the  scarlet  fever. 

Acufc  ucpJirifis  is  one  of  the  forms  of  nephritis  that  sometimes 
attacks  a  scarlet  fever  patient,  and  suppression  of  urine  may  be  the 
first  symptom  of  this  disorder.  In  certain  eases  of  scarlet  fever 
the  infection  seems  so  virulent  that  the  kidneys  may  be  completely 
suppressed  in  their  function  very  early  in  the  disease,  or  a  great 
diminution  in  the  urinary  flow  takes  place,  with  the  presence  in  the 
urine  of  large  quantities  of  albumin,  many  casts,  and  sometimes 
blood.  In  these  cases  death  may  ensue  in  a  very  short  time,  but 
more  often  the  function  of  the  kidneys  is  partially  restored  and  the 
patient  recovers  after  a  prolonged  convalescence. 

The  renal  changes  of  scarlet  fever  are,  therefore,  to  be  carefully 
watched,  for  the  condition  is  an  unusually  treacherous  one.  The 
greatest  care  must  be  exercised  that  the  kidneys  are  not  allowed 
to  become  congested  as  the  result  of  exposure,  for  any  additional 
congestion  may  change  a  mild  renal  condition  into  a  desperate  one. 

Postscarlatinal  nephritis  usually  develops  after  the  acute  symp- 
toms of  scarlet  fever  have  disappeared.  As  already  stated,  most 
of  the  cases  are  found  to  occur  during  the  third  week  of  the  disease, 
but  albuminuria  and  casts  may  appear  as  late  as  several  months 
subsequent  to  an  attack  of  scarlet  fever. 

The  importance  of  making  repeated  examinations  of  the  urine 
after  either  a  mild  or  a  severe  attack  of  scarlet  fever  cannot  be 
too  strongly  emphasized. 

Respiratory  System. — Perichondritis  of  the  larynx  is  a 
rare  and  usually  a  fatal  complication.  Krause^  states  that  this 
affection  occurs  once  in  200  to  250  cases  of  scarlet  fever,  but  this 
statement  is  not  borne  out  by  statistics  in  American  hospitals. 
Rauchfuss'  saw  4  cases  among  903  patients  suffering  from  scarlet 
fever,  and  Leichtenstern^  2  cases  among   4G7  patients  suffering 


■  Hunter.     Tlie  Practitioner,  January,  1909,  p.  3. 

-'  Krause.     Prag.  med.  Wochensclirift,  1899,  pp.  29,  30. 

'  Rauchfuss.     Quoted  by  Welch  and  .Schamberg,  .\cute  Contagious  Diseases,  p.  427. 

*  Leichtenstern.     Deutsche  med.  Wochenschrift,  1882,  p,  3173. 


ciitcuLATOiiY  hvsti-:m  329 

from  lli(^  .sjunc  disease.  The  (l<'\'cl(ipiiicii(  of  llii.  '■oiii|)li';iti(,i) 
often   iiecessiliiU'S  llu;  jx'rfoniiJiiicc  of  iiidiUiilion  of  li'aclicotoiiiv. 

Bkon(.'iioi'Ni<;um()Nia  is  a  fju'rly  rrc(|iiciif.  coiiiplicjilion  of  sfarlet 
fever,  partieuliirly  in  iiilniils.  Ho/j;er'  sfjifcs  lli;i(,  in  oil  eases  of 
scarlet  fever  in  infants,  0,  or  10.7  per  cent.,  were  eoni|)lif;itc(l  )>y 
bronchopneumonia.  Of  4,30  cases  of  scarlet  fever  in  diildren, 
(),  or  1.3  per  cent.,  developed  this  complication,  while  of  1727  cases 
of  scarlet  fever  affecting  adults,  4,  or  0.2  jxt  cent.,  dcvclf>j)((l 
bronchopneumonia.  In  the  series  of  08  fatal  cases  of  scarlet  fever 
reported  by  McColluni,^  15  were  due  to  l)ronchopneumonia.  In 
McCrae's'  series  of  325,  3  developcfl  this  complication  and  all 
three  died;  and  Henoch'*  remarks:  "We  found  bronchitis  and 
bronchopneumonia  in  nearly  all  severe  cases."  Pearce,''  in  a 
series  of  23  autopsies  upon  scarlet  fever  subjects,  found  broncho- 
pneumonia in  eight. 

Lobar  Pneumonia.^ — Lobar  pneumonia  is  a  rare  complication 
of  scarlet  fever,  and  when  seen  usually  complicates  this  disease 
in  an  adult.  Leichtenstern"  states  that  acute  lobar  pneumonia, 
sometimes  bilateral,  appears  at  the  height  of  the  primary  disease, 
but  it  has  been  noted  but  few  times,  and  more  often  in  association 
with  the  nephritis  caused  by  the  scarlet  fever. 

Pleurisy  and  Empyema. — Pleurisy  and  empyema  are  infre- 
quent complications  of  this  malady.  Pleurisy  is  most  likely  to 
complicate  severe  forms  of  the  disease,  especially  those  that  are 
complicated  by  gangrenous  processes  in  the  throat,  and  in  these 
particular  cases  the  pleuritic  effusions  often  become  purulent. 
McCrae^  found  two  cases  of  pleurisy  among  his  325  cases  of  scarlet 
fever,  and  Pearce^  discovered  one  in  29  autopsies  upon  scarlet 
fever  subjects.  Empyema  is  usually  a  late  complication,  often 
being  discovered  long  after  the  initial  illness. 

Circulatory  System.— Cardiac  changes  caused  by  the  toxins  of 
scarlet  fever  or  by  the  toxins  of  the  secondary  infections  during  the 

1  Roger.     La  Maladies  Infectieuses. 

2  McCollum.     Boston  City  Hospital  Reports,  Series  10,  1S99. 
^  McCrae.     Montreal  Medical  Journal,  September,  1908. 

■•  Henoch.     Charitt?  Annalen  III,  Jahrgang,  1S76,  p.  553. 

^  Pearce.     Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1899. 

^  Leichtenstern.     Deutsche  med.  Woch.,  1882.  pp.  246  et  seq. 

McCrae.      Montreal  Medical  Journal,  September,  1908. 

Pearce.      Report  of  Boston  City  Hospital,  1899. 


330  SCARLET  FEVER 

disease  are  among  the  most  important  complications  of  this  disease, 
and  rank  second  in  importance  to  the  kiihiey  comphcations. 

Mi/ocardiiis  is  the  condition  of  the  heart  which  is  most  frequently 
calleil  into  existence  hv  the  scarlatinal  toxin  and  the  secondary 
toxivmias.  Everv  severe  attack  of  scarlet  fever  probably  produces 
some  degree  of  myocarditis.  This  makes  it  ])articularly  necessary 
that  great  care  should  be  exercised  not  only  during  the  illness,  but 
throughout  the  convalescence,  that  no  undue  strain  be  placed  upon 
the  weakened  and  diseased  heart  muscle. 

Endocarditis  is  a  relatively  infrequent  complication  of  scarlet 
fever,  but  a  very  important  one.  There  has  long  existed  a  differ- 
ence of  opinion  among  clinicians  as  to  the  frequency  of  this  complica- 
tion during  scarlet  fever.  Ashljv^  found  endocarditis  not  uncom- 
mon  during  the  disease,  particularly  when  the  scarlet  fever  was 
complicated  by  synovitis  and  arthritis.  Roger,"  on  the  other  hand, 
considered  endocarditis  an  uncommon  complication.  In  a  series 
of  2213  cases  of  scarlet  fever  he  saw  only  two  cases  of  true  endo- 
carditis, but  noted  murmurs  not  due  to  actual  valvular  lesions 
692  times. 

]McCollum,^  in  an  analysis  of  1000  cases  of  scarlet  fever,  states 
that  a  mitral  systolic  murmur  was  detected  in  187  cases;  bruit  de 
gallop  in  5  cases;  irregular  action  of  the  heart  in  54  cases;  endo- 
carditis in  3  cases.  Many  of  the  murmurs  referred  to  were  thought 
to  be  due  to  a  relaxation  of  the  heart  muscle  as  a  result  of  the  action 
of  the  scarlatinal  toxin.  Daniel,^  in  studying  304  cases  of  scarlet 
fever,  found  that  although  in  66  murmurs  were  to  be  heard,  in  only 
3  cases  did  the  murmurs  remain  permanently.  Eddy^  observed 
but  3  cases  of  endocarditis  among  225  cases  of  scarlet  fever, 
and  Cheadle"  states  that  he  observed  15  cases  of  endocarditis 
during  scarlet  fever.  Henoch^  observed  two  cases  of  endocarditis 
(luring  scarlet  fever  which  were  followed  bv  chorea,  and  Schmoltz,^ 
of  Dresden,   in  30  autopsies  upon  scarlet  fever  patients,  found 

"  Ashby.     Medical  Chronicle,  January,  1894,  p.  161. 

-  Roger.     Les  Maladies   Infeetieuses. 

'  McColluni.     Boston  City  Hospital  Reports,  loc.  cit. 

*  Daniel.     Journal  American  Medical  Association,  1900,  xxxiv,  536. 

^  Eddy.     American  Journal  of  Obstetrics.  1907,  Ivi,  493. 

»  Cheadle.     Lancet,  1885,  ii,  705.  '  Henoch.     Charit(5  Annalen,  1876,  iii,  538. 

8  Schmoltz.     Miinch.  med.  Woch.,  1894,  li,  1417. 


ciucuLATOiiY  svsy /■:.]/  '/,:>,] 

3  cases  of  ciKlocjinlilis.  lie  concliKlcd  rinin  lii  :  ,111'lics  tt);it.  the 
majority  of  tlic  hc'iil  s\ mpioiiis  (lniin;^-  ^ciirld  i'cver  were  due. 
to  the  varyiii;;'  <;rii(lcs  oF  iiiyociir<li(is,  uliifh  he  foiiiKl  in  '.)  out,  of 
30  cases. 

In  the  report  of  the  Metropolitan  Asylum's  F>f>;inl  for  1007  we 
find  that  in  220()  cases  of  scarlet  fever  erulocarditis  occurred  in  120, 
or  0.58  per  cent.  In  the  statistics  of  the  J^ondon  Fever  Hospital 
for  the  last  five  years  the  percentage  of  cases  showing  endocarditis 
was  1.8  per  cent.  Hunter^  states  that  he  met  witli  hut  one  fatal 
case  of  endocarditis  in  1000  cases  of  scarlet  fever.  Jn  this  case  the 
patient,  a  young  child,  died  after  five  days'  illness,  and  at  the  autopsy 
the  mitral  valve  was  found  to  be  covered  with  enormous  masses 
of  soft  vegetations. 

Pericarditis  is  a  less  common  complication  of  scarlet  fever  than 
is  endocarditis,  but  like  the  latter  lesion  usually  occurs  in  severe 
septic  cases  of  scarlet  fever  which  are  so  often  complicated  by 
septicaemia  or  arthritic  symptoms.  This  complication  is  also 
occasionally  found  in  cases  of  scarlet  fever  that  are  complicated 
by  nephritis. 

Roger^  has  observed  several  cases  of  plastic  pericarditis,  both  at 
the  height  of  the  primary  disease  and  during  convalescence. 

Hodger,^  Pospischill,^  Beatty,''  Spencer,"  and  Barbier'  have  all 
reported  instances  of  this  complication,  but  ^Yelch  and  Schamberg^ 
state  that  it  has  been  a  very  rare  complication  in  the  large  number 
of  cases  that  have  been  under  their  care  at  the  ^Municipal  Hospital 
of  Philadelphia. 

In  the  experience  of  the  ^letropolitan  Asylum's  Board  of  London 
the  percentage  of  incidence  of  pericarditis  was  O.S  per  cent.,  and  the 
percentage  in  the  London  Fever  Hospital  was  0.15  per  cent.  When 
we  consider  how  large  a  number  of  scarlet  fever  patients  pass 
through  these  hospitals  in  a  year  it  is  evident  that  pericarditis  is 
a  comparatively  rare  complication  during  scarlet  fever. 

1  Hunter.     The  Practitioner,  January,  1909.  -  Roger.     Les  Maladies  Infectieuses. 

5  Hodger.     See  Eichhorst,  Specielle  Pathologie  und  Therapie  (Leipzig.  1S97). 

1  Pospischill.     Wien.  klin.  Woclienschrift.  September  12.  1907.  p.  10S9. 

^  Beatty.     Dublin  Journal  of  the  Medical  Sciences,  1907,  Ixxx,  11  to  29. 

s  Spencer.     Lancet,  1905,  i,  420  to  422. 

"  Barbier.     Journal  de  Med.  de  Paris,  1907.  ii,  xix,  p.  310. 

s  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  407. 


332  SCARLET  FEVER 

Phlebitis  is  a  rare  complication  of  scarlet  fever.  The  veins  of  the 
neck,  upper  extremities,  and  cranial  cavity  are  those  most  likely 
to  be  ali'ected.  As  would  be  expected,  this  complication  occurs  in 
the  very  severe  forms  of  the  disease,  particularly  in  those  affected 
with  gangrenous,  ulcerative,  or  suppurative  processes  about  the 
mouth  and  neck.  Cases  have  been  reported  by  Rees,^  Hofnagels,^ 
von  Jurgensen,^  and  Moizard  and  Ulmann.^  The  latter  writers 
were  able  to  collect  from  the  literature  only  four  cases  of  phlebitis 
following  scarlet  fever.  Roger'  reported  the  case  of  a  woman, 
aged  forty-nine  years,  who  died  on  the  eleventh  day  of  a  severe 
scarlet  fever  infection.  For  three  days  before  her  death  she 
suffered  from  phlebitis  of  the  crural  vein,  and  at  autopsy  vegetations 
were  foimd  on  the  auricular  surfaces  of  the  mitral  valves.  In  all 
the  cases  of  phlebitis  tluring  scarlet  fever  that  have  been  studied 
bacteriologically  the  condition  has  been  found  to  be  due  to  the 
streptococcus." 

The  Alimentary  Canal. — The  alimentary  canal  during  scarlet 
fever  is  the  subject  of  many  complications,  many  mild  and  without 
danger,  and  several  severe  in  their  course. 

Siomafitis  is  often  a  troublesome  early  complication,  particularly 
in  voung  and  poorly  nourished  children,  and  varies  in  severity  from 
very  mild  manifestations  to  the  gangrenous  cases  considered  under 
the  term  of  Noma  (see  below).  The  mucous  membrane  of  the  lips 
is  commonly  swollen  and  reddened,  and  their  epithelial  covering  is 
often  lost,  which  leads  to  superficial  ulcerations  and  may  cause 
fissures  about  the  mouth  which  not  only  cause  pain,  but  often 
seriously  interfere  with  the  administration  of  food. 

Tonsillitis  and  Angina  Pseudomemhranosa  or  Gangranosa. — 
Tonsillitis  occurs  much  more  frequendy  in  adults  and  older  chil- 
dren than  it  does  in  infants.  A  predisposition,  moreover,  is  seen 
in  those  patients  who  are  already  subjects  of  throat  affections. 
Although  tonsillitis  during  scarlet  fever  often  proves  a  mild  dis- 
order, it  may  readily  become  a  very  severe  one  when  associated  with 

'  Rees.     Lancet,  1862,  ii,  63. 

=  Hofnagels.     Ann.  Soc.  de  M^d.  des  Enfants,  1899,  vol.  ii.  No.  10.  p.  001. 

3  Von  .Jurgensen.     Archives  de  Mdd.  des  Enfants,  1899,  vol.  ii.  No.  10,  i>.  001. 

*  Moizard  and  Ulmann.     Archives  de  Mdd.  des  Enfants,  vol.  ii,  p.  601. 

'  Roger.     Les  Maladies  Infectieu.ses. 

"  Moizard  and  Ulmann.     Loc.  cit.,  p.  601. 


77//';  AUMh'NTAnV   CANAL  \\'.>;.\ 

an  iiifhimcd  and  confi^'cslcd  pliary/ix.  'llic  tonsils  ol"(cn  iK-fornf 
covered  wiUi  ifrennlar  piilclies  of  exudate,  wliieh  is  usually  diM-  to 
the  sti'eptoeoeeus,  idflioii^li  occasionally  the  k'lcl)-,-i.of(ilcr  hnciNns 
is  found.  Jn  severe  cases  the  tonsils  are  greatly  swollen  and  f:ovcrcd 
by  grayish  white  membrane,  which  spreads  raf)idly,  covering  the 
posterior  pharyngeal  wall,  the  hard  |>ala(e,  and  the  mucous  mem- 
brane of  the  posterior  surface  of  the  cheeks.  With  the  extension 
of  the  membrane,  which  varies  in  color  from  gray  to  almost  black, 
there  follows  a  severe  necrosis,  ulceration  and  sloughing  f>f  the 
tissues,  and  the  clinical  picture  becomes  one  of  prot'outid  s«'ptica'mia. 

In  a  small  percentage  of  the  cases  the  local  process  in  the  pharynx 
early  assumes  a  gangrenous  type  and  gives  rise  to  numerous  ulcera- 
tions affecting  not  only  the  tonsils,  but  the  pillars  of  the  pharynx, 
the  uvula,  and,  in  rare  instances,  the  deeper  cellular  tissues  of  the 
neck.  Guindesse,^  Mery  and  Halle,^  De  Brehler,^  and  Gindes* 
have  all  reported  such  cases  under  the  name  of  "primary  per- 
forating angina  during  scarlet  fever."  Closelv  allied  to  these 
gangrenous  processes  is  the  condition  known  as  noma,  which  is 
occasionally  seen  during  scarlet  fever,  although  it  occurs  much  less 
frequently  than  in  measles. 

Tourdes,^  who  analyzed  98  cases  of  noma,  found  that  only  5 
complicated  scarlet  fever,  while  Woronichin''  found  that  4  of 
22  cases  of  noma  complicated  severe  cases  of  scarlet  fever.  It 
is  fortunately  a  rare  condition,  for  it  is  extremely  fatal,  although 
during  the  last  year  Dr.  W.  J.  Roe,  of  the  Jefferson  Medical  College 
Hospital  Staff,  has  had  most  gratifying  success  in  several  cases  of 
noma  complicating  measles  by  the  administration  of  diphtheria 
antitoxin. 

Retropharyngeal  abscess  may  occur  as  the  result  of  the  burrowing 
of  pus  from  suppurating  glands  or  from  direct  infection  from  the 
ulcerating  surface  in  the  tlu"oat.  Bokai^  observed  this  complica- 
tion seven  times  in  664  cases  of  scarlet  fever  in  children.     In  six 

1  Guindesse.     Semaine  M^d.,  1906,  p.  13S. 

-  Mery  and  Halle.     Ann.  de  M^d.  et  Cliir.  Inf.,  Paris,  1903,  \-ii,  -403. 

3  De  Breliler.     Arch,  de  med.  d.  enf.,  1907,x.  22-1. 

^  Gindes.     Yratcli.  Gaz.  St.  Petersb.,  1905,  xii,  1323  to  1355. 

5  Tourdes.      Tli^se  de  Strassburg,  1S9S. 

s  Woroniehin.      Jahrbueh  f.  Kinderlieilk.,  1SS7,  xxvi.  161. 

7  Bokai.     Jahrbueh  f.  Kinderlieilk.,  X.  F.,  Band  x.  p.  108. 


334  SCARLET  FEVER 

of  these  cases  this  author  attributed  this  compHcatiou  to  the  break- 
ing down  of  the  retropharyngeal  glands.  In  one  of  Bokai's  cases, 
that  ended  fatally,  llie  rctrophai-yugeid  abscess  was  seen  as  early 
as  the  fifth  day  of  the  primary  illness.  We  have  seen  three  cases 
of  very  severe  scarlet  fever  which  developed  retropharyngeal 
abscess  during  the  second  week  of  the  disease,  but  all  tlu-ee  recovered 
after  a  somewhat  prolonged  convalescence. 

Gastritis  is  a  common  complication  of  scarlet  fever,  and  may  be 
very  severe,  although  our  knowledge  of  this  condition  is  largely 
based  upon  the  findings  in  fatal  cases.  Crooke*  found  catarrhal 
gastritis  in  each  of  six  cases  examined,  and  several  of  these  also 
showed  interstitial  as  well  as  follicular  gastritis.  Hesselwarth" 
found  21  cases  of  severe  gastro-enteritis  among  81  autopsies  upon 
scarlet  fever  subjects,  and  Pearce's^  findings  in  6  cases  showed 
similar  changes. 

Vomiting,  which  is  so  common  as  an  initial  symptom,  is  seldom 
troublesome  enough  to  unfavorably  influence  the  course  of  the 
disease,  although  in  the  severely  toxic  cases  it  may  become  danger- 
ous. In  the  hemorrhagic  cases  of  scarlet  fever,  the  material 
vomited  often  contains  blood,  and  in  some  instances  in  which  the 
hemorrhage  is  very  free  the  blood  is  ejected,  looking  as  if  it  had 
just  come  from  a  freelv  bleedino-  vessel. 

During  the  later  stages  of  scarlet  fever,  vomiting  may  be  an 
expression  of  the  toxaemia  of  a  complicating  nephritis. 

Diarrhcca  is  a  frequent  symptom  during  the  period  of  invasion 
in  severe  cases  of  scarlet  fever,  and  is  not  at  all  rare  in  ordinary 
cases,  although  the  frequency  of  this  symptom  varies  greatly  in 
different  epidemics.  It  is  due  to  a  catarrhal  enteritis,  which 
usually  yields  to  simple  treatment.  A  severe  attack  of  scarlet 
fever  in  a  young  child  is  nearly  always  complicated  by  enteritis 
accompanied  by  many  loose  movements,  with  green  stools,  fre- 
quently with  mucus,  and  occasionally  with  bloody  stools.  JoeP 
reports  a  case  in  which  severe  gastro-intestinal  symptoms  and  high 
fever  were  the  most  conspicuous  symptoms  of  the  illness.     Slight 

'  Crooke.     Quoted  by  Welch  and  Scliamberg,  loc.  cit.,  p.  443. 
2  Hesselwartli.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  443. 
'  Pearce.     Bo.ston  City  Hospital's  Medical  and  Surgical  Reports,  1899. 
■*  Joel.     Quoted  by  Thomas  in  von  Ziemssen's  Cyclopaedia  of  Medicine. 


77//';  A/JMJ'JNTA/fV   CANAL  WVy-y 

arifi'iiiii.,  followed  hy  .siibscfjiiciii  (lcs((ii;iiii;ili<)n  <»!'  iIk-  I. in,  ;iiiil  ;iii 
attiick  ol"  scarlet  fever  in  anollicr  iiicnihcr  of  the  r;iiiiil\ ,  rciiflcrcl  iIk- 
(liiig'iiosis  clenr.  in  (lie  l;ii(^r  slii^cs  of  (he  (|i,sc;isc  tlicic  i,  ouk- 
tiiiie.s  eiicomitered  ;i  (ly.senl,erie  coiKJilioii,  eli;ir;i(tcii-/.e(|  Ity  fre(|iici)t 
•siiiiill  cniiirrlial  or  Moody  slools,  with  tenesiiiiis.  Litteii'  refers  to 
the  oeciirrence  of  diarrhci'as  of  a  ty})lioid;d  (iijiritclcr.  in  diese 
cases  there  is  marked  distention  of  tlie  ahdoinen  and  in  scenic  of 
them  hemorrhages  from  the  bowel.  At  autopsy  there  is  found 
enhxrgement  of  the  spleen,  swelling  of  Peyer's  patches  and  of  the 
solitary  follicles,  the  latter  at  times  exhihidni;  erosions.  A  re[)ort 
as  to  the  Widal  reaction  is  not  given  with  these  cases,  mid  the 
possibility  must  be  l)()rne  in  mind  that  these  may  have  been  in- 
stances of  true  typhoidal  infection,  in  which  scarlalinifonn  rashes 
obscured  the  true  diagnosis. 

Pearce,^  Crooke,"'  and  Hesselwarth, '  in  their  autopsies  of  scarlet 
fever  subjects,  all  noted  hyperplasia  and  necrosis  of  the  lymph 
follicles,  and  Crooke  states  that  in  these  cases  Peyer's  patches  not 
infrequently  resemble  those  found  in  typhoid  fever  in  the  early 
stage  of  the  disease. 

The  liver  in  scarlet  fever  has  been  reported  by  many 
observers  as  being  increased  in  size,  the  inferior  border  being 
palpable  below  the  false  ribs.  Welch  and  Schamberg,'  Corlett," 
and  others  state  that  although,  in  their  experience,  the  liver  is  gen- 
erally enlarged  during  this  disease,  this  finding  is  not  a  constant  one, 
and  the  organ  may  in  severe  cases  be  much  diminished  in  size  as  the 
result  of  degeneration.  Histologically  the  changes  in  the  liver  are 
those  found  in  all  the  acute  infectious  fevers.  Pearce^  examined 
22  cases,  and  found  that  4  showed  distinct  fatty  degeneration  and 
7  fatty  infiltration,  while  focal  necrosis  was  found  in  4  cases.  The 
findings  of  Roger  and  Garnier  in  their  examination  of  12  cases  at 
autopsy  were  practically  the  same  as  those  of  Pearce. 

Cirrhosis  of  the   liver  as  a  sequel    to  scarlet  fever  has  been 

1  Litten.     Charite  Annalen,  vol.  vii,  pp.  12S  et  seq. 

-  Pearce.     Medical  and  Surgical  Reports  of  Boston  City  Hospital,  1899. 

'  Crooke.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  443. 

^  Hesselwarth.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  443. 

5  W^elch  and  Schamberg.     Acute  Contagious  Diseases,  p.  442. 

^  Corlett.     Acute  Infectious  Exanthemata,  p.  211. 

'  Pearce.     Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1S99. 


336  SCARLET  FEVER 

reported  bv  Rinoie/  who  saw  this  coiitlitlon  several   times  among 
chil.lreii. 

Postmortem  examination  in  S  of  his  cases  revealed  nnmistakable 
degeneration  of  the  liver  cells. 

Jaundice  in  scarlet  fever  is  not  a  frequent  complication  of  the 
disease,  but  is  met  with  in  certain  epidemics,  particularly  among 
severe  cases.  McCollunr  states  that  jaundice  appeared  15  times 
in  a  total  of  oOOO  cases  of  scarlet  fever  collected  bv  him  at  the 
Boston  City  Hospital,  and  Barlow'*  found  that  this  symptom  was 
notetl  in  15  of  the  10,000  cases  of  scarlet  fever  treated  at  the 
London  Fever  Hospital. 

Kaupe,^  Shostak,''  Gross,"  and  Byalokur^  have  noted  jaundice 
during,  and  Phillips,*  Barlow,^  and  Klingmuller'"  following,  attacks 
of  severe  scarlet  fever.  Mild  jaundice  has  no  particular  signifi- 
cance during  an  attack  of  scarlet  fever,  but  severe  jaundice  may 
indicate  degeneration  of  the  liver.  Roger"  is  of  the  opinion  that 
delirium  and  great  variations  of  the  temperature  during  scarlet 
fever  are  often  to  be  explained  by  the  pathological  changes  in  the 
liver  cells,  and  Baginski'-  states  that  he  considers  the  appearance 
of  jainidice  in  a  case  of  scarlet  fever  that  is  complicated  by  nephritis 
to  be  of  grave  import,  as  in  liis  experience  this  ushers  in  a  very 
severe  urpemic  condition.  Possibly  some  of  these  cases  are  in 
reality  instances  not  of  hepatogenous  but  hematogenous  jaundice. 

Peritonitis  is  an  exceedingly  rare  complication  of  scarlet  fever, 
and  is  due  in  the  majority  of  cases  to  streptococcus  infection  of  the 
peritoneum.  McCollum  and  Blake"  have  reported  two  cases  of 
this  complication. 

It  is  to  be  remembered  that  ascites  developing  during  scarlet 
fever  is  a  fairly  frequent  occurrence,  being  due  either  to  a  compli- 

'  Single.     Jahrbuch  f.  Kinderheilkunde,  Ixv,  No.  4. 

■  McCollum.     Boston  City  Hospital  Reports,  1899,  Series  10. 

'  Barlow.     British  Medical  Journal,  August  4,  1906. 

*  Kaupe.     Miinch.  med.  Wochenschrift,  1906,  liii,  314. 

5  Shostak.     Vratch.  Gaz.  St.  Petersb.,  1903,  x,  1168. 

'  Grcss.     Miinch.  med.  Wochensciirift,  1905,  Hi,  2326. 

7  Byalokur.     Prakt.  Vratch.  St.  Petersb.,  1907,  vi,  211  to  213. 

8  Phillip.?.     Lancet,  March  21,  1908.  ^  Barlow.     Loc.  cit. 
">  Klingmuller.     Aerztl.  Prax.,  Berlin,  1906,  xix,  182. 

"  Roger.     Les  Maladies  Infect ieuses. 

'2  Baginski.     Die  Kinderkrankheiten,  1889,  p.  117. 

''  McCollum  and  Blake.     Boston  Medical  and  Surgical  Journal,  December  10,  1903. 


Till':  Ni'jiivous  ^YHTi'hM  ;j;i7 

oatiiifi;  ncpln'ili's  or  ii,  fnilinj^-  licncl,  or  in  sonic  in.slMiif^c.s  to  hotli 
C'iinscs. 

The  Nervous  System.  'V\u-  hcinous  syslcm  ->iifrci^  iiunkcfJIy 
during  scarlet  fever.  Tlic  onsd  ol'  the  disease  is  atteruK-d  in  many 
oases  by  marked  ji(>rvons  symf)toms,  siieli  as  headaelie,  drowsiness, 
delirium^  convulsions,  and  occasionally  hy  coma.  Tliese  symf>- 
toms  usually  abate  if  the  course  of  the  disease  be  r;i\-or;d»lf,  ;ind  do 
not  necessarily  add  to  the  gravity  of  the  disease.  Tiie  early  cere- 
bral manifestations  are  due  to  the  effects  of  the  scarlatinal  poison 
as  v^ell  as  to  the  high  temperature  present,  and  in  some  cases  the 
delirium  of  onset  persists  for  days  and  not  infrecjuently  until  die 
death  of  the  jiatient. 

Insanity  during  or  following  scarlet  fever  is  rare  and  the  mental 
condition  is  usually  temporary,  but  may  in  some  cases  persist  after 
convalescence.  Mitchell,^  Rabuske,^  and  Wagner^  have  each 
reported  cases  of  acute  mania  during  an  attack  of  scarlet  fever. 

Mania  during:  scarlet  fever  has  been  noted  to  have  followed 
ursemic  convulsions,  and  Carrieu*  and  Brille'^  have  each  reported 
cases  of  insanity  occurring  as  sequels  of  scarlet  fever.  ^Melancholia 
is  a  rare  sequel,  and  usually  is  short  in  duration. 

Meningitis  during  scarlet  fever  is  a  rare  complication,  and  when 
seen  is  usually  due  to  the  extension  of  the  infective  process  from 
the  middle  ear  or  from  the  nasal  sinuses,  or,  more  rarely,  is  caused  by 
infective  emboli  which  infect  the  meninges  at  the  height  of  the  disease. 

When  meningitis  develops,  it  is  an  extremely  serious  affec- 
tion, and  death  usually  occurs  within  a  week  of  the  onset  of  the 
symptoms.  Welch  and  Schamberg,"  Roger,'  and  Baudelocque^ 
report  instances  of  this  complication  during  the  acute  stage  of  the 
disease. 

Meningo-encephalitis  and  cerebrospinal  meningitis  are  both  rare 
■complications  of  scarlet  fever,  but  the  former  has  been  reported 

1  Mitchell.     Edinburgh  Medical  Journal,  February,  1S82. 

-  Rabuske.     Deutsche  med.  Wochenschrift,  October  S,  1881. 

3  Wagner.    Quoted  by  von  Jurgensen  (Nothnagel's  Encylopadia  of  Practical  Medicine). 

•>  Carrieu.     New  England  Medical  Monthly,  1882-1883,  ii,  55  to  58. 

5  Brille.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  -429. 

8  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  403. 

^  Roger.     Les  Maladies  Infectieuses. 

«  Baudelocque.     Gaz.  des  hop.  de  Paris,  1837,  ii,  197  to  199. 

22 


33S  SCARLET  FEVER 

by  Baudelocque/  Avhose  patient  suffered  from  headache,  vomiting, 
and  convulsions,  followed  by  coma,  loss  of  speech,  loss  of  hearing, 
and  blindness.  Cerebrospinal  meningitis  has  been  reported  by 
Althaus,-  ^NIcKenzie,^  Leroux,^  and  Leichtenstern.'^  Althaus  states 
that  his  patient  not  only  hatl  spinal  meningitis,  but  also  developed 
consecutive  lateral  and  posterior  sclerosis. 

Hemiplegia  is  also  a  rare  complication  of  scarlet  fever.  It  may 
occur  early  in  the  course  of  the  disease  as  the  result  of  a  cerebral 
hemorrhage  or  may  come  on  at  a  later  date  as  the  result  of  embo- 
lism or  thrombosis.  Taylor"  has  reported  a  right-sided  hemiplegia 
resulting  from  embolism  of  the  middle  cerebral  artery.  Sufrin^  has 
reported  a  similar  case  seen  by  him,  and  Osier*  states  that  scarlet 
fever  was  the  cause  of  seven  of  his  series  of  120  cases  of  infantile 
hemiplegia,  Addy*^  reports  a  case  of  what  he  calls  "partial  hemi- 
plegia with  amnesia,"  which  appeared  as  a  complication  during 
the  convalescence  of  one  of  his  scarlet  fever  patients.  Rolleston^** 
has  summarized  the  literature  upon  this  subject  when  reporting 
three  cases  of  hemiplegia  during  scarlet  fever.  These  three  cases 
were  found  in  a  series  of  10,781  cases  of  scarlet  fever.  Rolleston 
found  63  cases  in  the  literature,  this  making  GG  in  all. 

Of  58  of  these  cases,  the  right  side  was  affected  in  43,  the  left 
in  15.  This  complication  occurred  at  any  time  during  the  disease 
from  the  first  week  to  the  sixth.  Of  the  G6  cases,  49  recovered, 
and  in  17  the  recovery  was  complete.  In  the  majority  of  the  cases, 
however,  contractures  and  atrophy  took  place.  In  28  cases  of 
right-sided  hemiplegia  there  was  associated  aphasia. 

Cherepnin"  reports  a  case  of  scarlet  fever  which  was  complicated 
by  aphasia,  but  does  not  mention  that  there  was  hemiplegia 
associated  with  this  symptom. 

1  Baudelocque.     Gaz.  des  hop.  de  Paris,  1837,  ii,  197  to  199. 

2  Althaus.     British  Medical  Journal,  1881,  i,  p.  50. 

3  McKenzie.     Glasgow  Medical  Journal,  1905,  Lxiii,  326. 

*  Leroux.     Bull.  Soc.  de  P(5diat.,  Paris,  1905,  vii,  277. 

^  Leichtenstern.     Deutsche  med.  Wochenschrift,  1882. 

8  Taylor.     Medical  Times  and  Gazette,  London,  1880,  ii,  686. 

^  Sufrin.     Spitalul.  Bucuresci,  1903,  pp.  23  to  25. 

*  Osier.     Practice  of  Medicine,  p.  985. 

'  Addy.     Glasgow  Med.  Jour.,  1880,  bcxxv,  13,  463  to  465. 
'"  Rolleston.     Medical  Review,  January,  1909,  p.  24. 
"  Cherepnin.     Prakt.  Vratch.  St.  Petersb.,  1903,  ii,  803. 


TJIK  N/':iiVOI/S  SYSTEM  :>;.',() 

Paraplegia  (liiriii<f  scailcl,  fever  is  ii  r.ncr  eoiupliejiiioii  lli;iii  is 
herni[)le<^i;i.  I(i,starie(\s  ol"  this  eornplieiilion  have  fjeen  re[K;rtwJ 
by  Dcinan^e/  Jlogcr,''  and  I'asUjrc.'*  I'astorc's  patients  were  all 
cliildrcn,  but  Roger  reported  three  instances  in  adults  who,  early 
in  convalescence,  experienced  great  difficulty  in  standing  or  walk- 
ing. These  cases  recovered  in  ten  days.  Roger  states  that  among 
2213  cases  of  scarlet  fever,  4  cases  of  incomplete  paraplegia  were 
observed. 

Progressive  paralysis  of  the  limbs  with  wasting  ha.s  been  observed 
very  rarely  in  this  disease,  and  presents  features  of  a  subacute, 
ascending  spinal  paralysis. 

Multiple  neuritis  following  scarlet  fever  is  one  of  the  rare  com- 
plications of  this  disease.  Egis^  has  reported  a  case  in  which  there 
was  an  ataxic  gait  and  paralysis  of  both  peroneal  nerves.  He  was 
able  to  find  but  two  similar  cases  in  the  literature,  which  gives  us 
an  idea  of  its  rarity.  Grocco'  has  reported  a  case  which  suffered 
from  this  complication.  He  gives  a  complete  autospy  report  with 
the  histological  findings,  which  appear  to  prove  that  the  neuritis 
present  was  due  to  the  scarlatinal  toxaemia.  Price,''  Hills,^  and 
Eulenberg^  have  all  reported  cases  of  multiple  neuritis  following 
scarlet  fever,  while  Hitzig,^  McEwen/°  and  Centeno"  have  reported 
localized  neuritis.  Hitzig's  patient  developed  a  double  brachial 
paralysis,  Centeno's  a  facial  diplegia,  while  one  of  Eulenberg's 
patients  had  a  double  median  paralysis  with  partial  facial  paralysis. 
In  all  of  these  cases  this  complication  appeared  during  con- 
valescence. 

Chorea  is  rare  as  a  complication  of  scarlet  fever,  and  when 
present  is,  as  pointed  out  by  Carslaw,^^  usually  associated  with  arth- 
ritis and  endocarditis.     This  writer  reports  that  only  three  cases  of 

1  Demange.     Bull.  Soc.  anat.  de  Paris,  1874,  pp.  503  to  509. 

-  Roger.     Les  Maladies  Infect  ieuses. 

^  Pastore.     Gior.  internaz.  de  Sc.  Napoli,  1906,  xxviii,  22. 

4  Egis.     Archiv  f.  Kinderheilk.,   1900,  28. 

5  Grocco.     Centralbl.  f.  Med.,  1885,  p.  693. 

8  Price.     British  Medical  Journal,  1906,  i,  914. 

^  Hills.     Northwest  Lancet,  Minneapolis,  1904,  i,  712. 

8  Eulenberg.     Functional  Nervenkrankheiten,  Berlin,  1891. 

5  Hitzig.     (Quoted  by  Putnam)  Boston  Medical  and  Surgical  Journal. 
1"  McEwen.     Archives  of  Pediatrics,  1905. 

"  Centeno.      Rev.  Soc.  med.  Argent  Buenos  Aires,  1904,  xii,  797  to  813. 
^-  Carslaw.     Quoted  by  Osier  in  his  monograph  on  Chorea  and  Choreiform  Affections. 


340  SCARLET  FEVER 

chorea  were  observed  to  follow  533  cases  of  scarlet  fever.  Priestly^ 
states  that  he  collected  thirteen  cases  as  sequels  to  5355  cases  of 
scarlet  fever.  IMoore-  states  that  chorea  may  develop  at  periods 
varying  from  two  to  six  months  following  the  attack  of  scarlet 
fever,  and  thinks  that  the  rarity  of  chorea  as  a  sequel  to  scarlet 
fever  is  accounted  for  by  the  fact  that  it  tlevclops  so  late. 

Choreiform  movcnicnis  are  sometimes  noted  thu'ijig  convalescence 
from  scarlet  fever,  but  are  a  rare  occurrence. 

Tetany  during  scarlet  fever  has  been  reported  very  rarely.  Stef- 
fern''  saw  a  case  suffering  from  this  complication,  and  Kuhn-Ulsar'* 
mentions  having  had  a  similar  case  under  his  care.  The  patient 
was  a  boy,  aged  foiu-  and  a  half  years,  who  was  convalescing  from 
scarlet  fever.  For  six  weeks  muscular  spasms  and  stiffness  were 
noted,  at  times  limited  in  extent  and  at  other  times  general.  Tris- 
mus was  present  for  foiu-teen  days,  but  the  boy  recovered  after  a 
prolonged  convalescence. 

Epilepsy  as  a  sequel  to  scarlet  fever  has  been  mentioned  by 
several  writers,  but  its  occurrence  appears  to  be  a  coincidence. 
Wildermuth^  states  that  in  187  cases  of  epilepsy  the  statement  was 
made  in  12  instances  that  the  first  attack  followed  a  severe  illness 
of  scarlet  fever. 

Skin  Lesions. — Among  the  complications  of  the  late  stages  of 
scarlet  fever  purpura  hcemorrhagica  is  infrequently  noted.  This 
condition,  which  is  sometimes  referred  to  as  purpura  fulminans,  is 
usually  a  very  serious  complication,  and  the  majority  of  the  cases 
so  affected  die.  Henoch,"  Davies,^  Risel,^  Collie,"  Strom,*"  Dercum," 
Lund,^'  Wilson,*^  Heubner,"  Miller,*^  Cullen,'«  and  Elliot*^  have  all 

1  Priestly.     British  Medical  Journal,  September,  1897,  p.  805. 

-  Moore.     Eruptive  and  Continued  Fevens,  New  York,  1892,  p.  171. 

'  Steffem.     Jacobi's  Festschrift,  1900,  p.  83. 

<  Kuhn-Ulsar.     Berl.  klin.  Wochenschrift,  1899,  No.  39,  p.  855. 

'  Wildermuth.     Quoted  by  Holt,  Children's  Diseases. 

•^  Henoch.     Prag.  med.  Wochenschrift,  1886,  ii,  494. 

^  Davies.     British  Med.  .Journal,  1891,  i,  658. 

«  Risel.     Zeitsch.  f.  klin.  Med.,  1905-1906,  Iviii,  162. 

'  Oillie.     Lancet,  1891,  i,  658.  «>  Strom.     Era  Gothenburg,  1887,  ii,  132. 

■'  Dercum.     Medical  and  Surgical  Reports,  1892,  Ixvii,  836. 
'2  Lund.     Norsk,  mag.  f.  Laegeuv.,  1871,  219. 

"  Wilson.     Arch.  Pediat.,  1895,  xii,  p.  679. 

"  Heubner.     Berl.  klin.  Wochen,  1908,  p.  1345.  »'  Miller.     Lancet,  April  8,  1905. 

'0  CuUen.     Brit.  Med.  .Jour.,  1903,  i,  197. 

"  Elliot.     Arch,  of  Internat.  Medicine,  April  15,  1909. 


PA  HOT  IT  IS  AM)  oik:  urns  ;^4I 

reported  inst.'inccs  of  tliis  fondilioii.  In  Klliot's  patient,  agwl 
ei^lit  and  one-half  years,  the  syinptoins  of  the  original  diseji-se  were 
very  severe,  and  seventeen  (hiys  after  the  onset  of  the  searlet  fever 
the  patient  cornphiined  of  a,  reditu  of  llic  soic  ilnoni,  ;iiid  two  days 
later  a  purpuric  s[)ot  on  the  ankle  aJid  a  litth;  later  ^an^renous 
areas  of  the  skin  were  seen.  Tlie  patient  died  sixty-eight  liours 
after  the  onset  of  the  purpura  and  twenty-two  days  after  onset 
of  the  scarlet  fever.  Elliot  found  in  the  literature  10  cases  of 
purpura  fulminans  that  were  sef|uel.s  to  an  attack  of  scarlet  fever. 

Abscesses.^ — Abscesses  of  different  portions  of  the  bfxJy, 
more  often  on  the  extremities  and  particularly  on  the  fingers,  are 
infrequently  noted  during  convalescence  from  scarlet  fever. 

Onychia. — Onychia  is  a  troublesome  complication  which  often 
affects  the  nails  of  children  who  are  convalescent  from  scarlet 
fever.  Its  frequency  among  children  is  explained,  at  least  in  great 
part,  by  the  tendency  of  such  patients  to  pick  at  the  desquamating 
skin  in  the  region  of  the  nail  matrix,  thereby  causing  a  focus  of 
infection  in  the  injury  done  to  the  new  skin. 

Ridging  of  the  nails  is  a  frequent  occurence  in  this  disease,  as  in 
all  severe  febrile  affections. 

Swelling  of  the  Thyroid  Gland. — Swelling  of  the  thyroid 
gland  is  one  of  the  very  infrequent  complications  of  scarlet  fever. 
It  is  occasionally  seen  during  this  disease,  as  it  is  in  nearly  all  the 
acute  infectious  fevers.  Roger  and  Garnier^  have  reported 
several  instances  which  occurred  during  epidemics  of  unusual 
virulence.  One  of  us  (Beardsley)  saw  a  well-marked  instance  of 
fills  complication  during  the  first  week  of  a  severe  attack  of  scarlet 
fever  in  a  girl,  aged  thirteen  years,  and  he  has  several  times  noted 
slight  puffiness  of  the  gland  during  the  height  of  the  fever  in  female 
patients. 

Parotitis  and  Orchitis. — Parotitis  and  orchitis  are  both  rare 
complications  of  the  disease,  but  they  have  been  observed,  usually 
being  associated  with  severe  attacks  of  the  disease.  Phillips"  has 
reported  an  instance  of  acute  parotitis  which  appeared  in  the  early 
stage  of  a  severe  attack  of  scarlet  fever. 

1  Roger  and  Garnier.      Virchow's  Archiv,  clxxiv,  1. 
-  Phillips.      Lancet,  March  21,  1908. 


342  SCARLET  FEVER 

Myositis. — ^Myositis  durinii'  or  following  scarlet  fever  is  a 
soiiiewimt  unusual  occurrence,  but  is  prol)al)ly  not  as  rare  as  the 
dearth  of  literature  upon  the  subject  would  indicate,  l^ruck'  has 
reported  several  cases,  and  is  inclined  to  think  the  conilition  a  not 
uncommon  one.  Somerset"  has  reported  an  instance  of  this  condi- 
tion which  developed  during  the  height  of  an  attack  of  scarlet 
fever  imder  his  care.  The  condition  is  characterized  by  local 
tenderness,  fever,  and  stiffness  in  muscles  in  vaiious  portions  of  the 
body.  The  junior  author  remembers  having  seen  a  number  of 
such  cases  during  his  interneship  at  the  Municipal  Hospital  of 
Philadelphia,  and  was  inclined  at  that  time  to  ascribe  the  symptoms 
to  slight  injuries,  such  as  bumps  against  the  cribs  when  the  children 
were  being  lifted,  but  no  history  of  injury  could  be  ascertained. 
Very  rarely  these  painful  areas  suppurate  and  discharge  a  thick 
bloody,  grumous  fluid. 

Necrosis  of  Bones. — Necrosis  of  bones  during  or  following 
scarlet  fever  is  rare.  It  is  well  known  that  necrosis  of  the  ear 
ossicles  and  even  the  petrous  portion  of  the  temporal  bone 
follows  scarlet  fever  in  not  a  few  instances.      (See  Otitis.) 

Brown^  has  seen  a  case  in  which  the  lower  maxilla  was  involved 
in  a  suppurative  process,  and  Weickert*  reports  a  case  in  which 
both  jaws  were  thus  affected.  Suppurative  artlu'itis  has  already 
been  considered  in  another  section  of  this  work,  while  osteitis  and 
periostitis  are  rare  complications  which  occasionally  attack  the 
nasal  bones  (Henoch),  the  temporal  bone,  as  above  mentioned,  and 
infrequently  the  cervical  vertebrae.  Neumark,^  who  reported  30 
cases  of  acute  infectious  osteomyelitis,  stated  that  5  of  them 
followed  attacks  of  scarlet  fever. 

Ocular  Complications. — Ocular  complications  are  not  un- 
common during  attacks  of  scarlet  fever,  although  a  study  of  the 
literature  does  not  give  one  a  correct  idea  of  their  frequency.  In 
severe  forms  of  the  disease,  particularly  in  forms  complicated  by 
piu-ulent  rhinitis,  a  severe  conjunctivitis  is  often  developed.     In 

>  Bruck.     Petersb.  Med.  Presse,  1896,  No.  18. 

-  Somerset.     New  York  Medical  Journal,  Ixxii,  No.  23. 

3  Brown.     Lancet,  1844,  i,  220. 

*  Weickert.     Deutsche  Klinik,  Berlin,  1854,  vi,  22. 

'  Neumark.     Archiv  f.  Kinderheilk.,  Band  xxii. 


OC (J LA R  COM I'LICA  TIONS  'M  'A 

ran;  cases  a  pscudorncinbrarioiis  conjiuK-fiviUs  occrurs.  'J'liis  is 
most  commonly  due  to  str('[)tococcic  inf'ectiorj,  less  ofteu  to  the 
Klebs-Loeffler  bacillus.  When  streptococcic  conjunctivitis  occurs 
it  is  a  serious  complication,  as  corneal  ulceration  of  a  vinil' nt 
nature  ensues  and  the  eye  in  many  instances  is  lost. 

Frimary  keratitis  is  frequently  observed  in  scarlet  fever 
wards,  but  few  cases  are  to  be  found  reported  in  the  lifcr.'idire 
of  scarlet  fever.  One  of  us  remembers  having  seen  tlircf;  cases  of 
well-marked  corneal  ulceration  in  a  series  of  less  than  fifty  cases 
of  scarlet  fever,  and  Dr.  Burvill-IIolmes  informs  us  that  while  a 
resident  physician  at  the  Municipal  Hospital  of  Philadelphia,  he 
observed  this  complication  repeatedly  in  scarlet  fever  patients,  in 
all  at  least  twenty-five  times.  The  complication  is  prone  to  occur 
in  scrofulous  subjects,  although  children  who  have  been  in  previous 
good  health  occasionally  develop  this  complication  during  even 
mild  attacks  of  scarlet  fever.  Leichtenstern^  reported  two  cases 
of  corneal  ulceration  and  one  of  hypopyon  keratitis  dm-ing  an 
epidemic  of  scarlet  fever  at  Cologne.  Schrotter^  states  that  the 
cornea  may  be  primarily  affected,  usually  in  the  way  of  rapidly 
progressing  ulcerative  processes. 

Choroiditis  may  in  rare  instances  complicate  scarlet  fever. 
Leichtenstern^  saw  such  a  case,  but  it  is  noteworthy  that  the  more 
important  ocular  complications  are  usually  secondary  to  scarlatinal 
nephi'itis.     Of  these,  ursemic  amaurosis  is  the  most  frequent. 

Albuminuric  retinitis  is  rare  in  all  forms  of  acute  nephritis,  and 
the  scarlatinal  type  is  not  an  exception.  It  may,  however,  result 
from  the  subsequent  chronic  nephritis. 

Amblyopia  may  complicate  the  kidney  condition,  but  after  some 
days  complete  restoration  of  vision  usually  occurs.  Welch  and 
Schamberg,*  Porter,^  and  DuvalP  all  report  such  cases. 

Orbital  cellulitis  is  a  rare  complication.  Burton  Chance'  has 
reported  two  cases,  and  Sidney  Phillips*  tliree  cases,  while  Porter^ 

1  Leichtenstern.     Deutsche  med.  Wochenschrift,  1882,  p.  3173. 
^  Schrotter.     Ziemssen's  Encyclopsedia  of  Medicine,  p.  ISO. 
5  Leichtenstern.     Deutsche  med.  Wochenschrift,  18S2,  p.  3173. 

*  Welch  and  Schamberg.     Acute  Infectious  Diseases,  p.  405. 

^  Porter.     Quoted  by  Thomas  in  Ziemssen's  Encyclopsedia.  ^  Duvall.      Ibid. 

'  Burton  Chance.     American  Medicine,  Jime  13,  1903,  p.  960. 

*  Sidney  Phillips.     Ophthalmoscope,  ilay,  1905.  '  Porter.     Loc.  cit. 


344  6C ABLET  FEVEli 

Diivall,*  Werner,-  Gregory/  and  Nettlesh'p^  have  all  reported 
single  instances.  Werner's  case  was  a  bov,  aged  six  vears,  who 
at  the  height  of  h's  scarlet  fever  developetl  unilateral  proptosis 
and  oedema  of  the  lids,  probably  due  to  thrombosis  of  the  cavernous 
sinus.  In  Nettleship's  case  there  was  also  unilateral  optic  atrophy. 
Both  the  cases  leported  by  Porter  and  that  of  Duvall  developed 
exophthalmos  caused  by  infiltration  of  the  cellular  tissues  of  the 
orbit  (see  below). 

Opiic  neuritis  is  another  rare  complication  during  scarlet  fever. 
Uhthoff^  studied  253  cases  of  optic  neuritis  due  to  various  infec- 
tious diseases,  and  found  that  only  three  were  due  to  scarlet  fever. 
Groenouw"  was  able  to  find  in  the  literature  five  cases  of  scarla- 
tinal optic  neuritis,  one  with  albuminuria  (Barlow's  case),  and  three 
without  this  symptom  (Betke,  Vance,  Pfluger). 

Other  ocular  comphcations  are  rare,  but  Hodges^  has  reported  a 
case  in  which  there  developed  embolism  of  the  central  artery  of  the 
retina  during  a  severe  attack  of  scarlet  fever. 

Kendall'  has  reported  a  case  of  dacryocystitis,  lyinder^  one  of 
dacryo-adenitis,  and  Lenhartz^  has  seen  paralysis  of  the  extrinsic 
ocular  muscles. 

Surgical  Scarlet  Fever. — Surgical  scarlet  fever  has  been  a 
mucli  discussed  subject  since  Sir  James  Paget  called  attention  to 
the  fact  that  patients  who  had  undergone  surgical  operations 
were  particularly  susceptible  to  scarlet  fever  infection.  Paget  s 
first  paper*  was  published  in  1804,  and  Paley  and  Goodhart* 
reported  25  cases  of  this  condition  in  1879.  House^°  also  reported 
an  epidemic  of  surgical  scailet  fever  in  a  hospital  for  children. 
From  the  time  of  these  early  reports  there  has  been  frequently 
seen  in  the  literatiu'e  accounts  of  surgical  scarlet  fever,  and  there 
seems  no  manner  of  doubt  that  solutions  of  continuity  of  the  skin 
render  a  patient  more  susceptible  to  the  disease.     Patients  with 

1  Duvall.     Loc.  cit.  -  Werner.     Ophthalmoscope,  May,  1905. 

'Gregory.     Quoted  by  Parsons,  Practitioner:  January,  1909.  <  Nettleship.     Ibid. 

'  Uhthoff.     Ibid.  "  Groenouw.      Ibid. 

'  These  authors  are  quoted  by  Parsons  in  his  article  on  Ocular  Complications  of  Scarlet 
Fever,  in  the  Practitioner,  January,  1909. 

*  Paget.     Clinical  Lectures  and  Essays,  1874. 
9  Paley  and  Goodhart.     Guy's  Hospital  Reports,  1879. 
>"  House.     Guy's  Hospital  Reports,  1879. 


lU'lLAI'SK  'Mr> 

extensive  surface  burns  are  piuiiciihnly  prone  fo  develop  sfjirlr-t 
fever.  It  must  never  he  for^ollcn,  li()W(-vci',  iIimI,  lli(Te  are  many 
cases  that  (leveh)p  toxic  rashes  (hie  I**  sepsis  without  having  true 
scarlet  fever. 

Relapse. — l{('la|)se  occurs,  hut  is  an  infrcrjufnt  sef|Ufl  to 
scarlet  fever,  it  is  well  known  that  the  rash  in  scarl(;t  fever  may, 
in  certain  cases,  disappear  and  recur  in  a  few  days.  Sueh  eruj>- 
uons  should  not  be  interpreted  as  a  true  relapse,  for  io  he  called  a 
relapse  the  patient  must  have  a  recurrence  of  all  the  prominent 
symptoms  of  the  original  diseaseas  well  as  the  rash, and  these  should 
appear  shortly  after  the  beginning  convalescence  from  the  original 
attack.  In  the  majority  of  the  cases  of  true  relapse  the  recurrence 
is  quite  as  severe  in  every  way  as  was  the  original  attack.  Korner^ 
has  reported  8  cases  in  which  the  relapse  proved  fatal,  and  Welch 
and  Schamberg^  quote  Richardson,  who  gives  an  interesting 
account  of  a  large  number  of  relapses  following  scarlet  fever  on 
board  the  frigate  "Agamemnon,"  in  which  epidemic  300  of  the  800 
men  suffered  from  the  disease.  Among  these  300  men  second 
attacks  were  frequent,  some  of  these  attacks  being  mild  but  others 
were  very  severe.  Sloan^  reports  154  cases  of  scarlet  fever  that 
had  a  relapse  among  14,143  scarlet  fever  cases.  Trujowsky^  states 
that  among  300  cases  of  scarlet  fever  there  were  18  which  had 
relapses.  Hose^  mentions  that  among  2453  cases  of  scarlet  fever 
there  were  15  cases  of  reinfection  which  occurred  between  the  third 
and  sixth  week  of  convalescence.  Lettre^  states  that  1.5  per  cent, 
of  scarlet  fever  cases  relapse,  and  Seitz^  states  that  in  his  experi- 
ence it  is  common  to  see  recurrence  of  the  rash  and  development 
a  second  time  of  the  primary  symptoms  after  eight  or  ten  days  of 
convalescence.  Slade-King^  reports  two  cases  of  relapse,  one 
occm'ring  on  the  twenty-ninth  and  the  other  on  the  thirty-fourth 
day  of  the  original  attack. 

1  Korner.     Ziemssen's  Encyclopsedia,  p.  190. 

-  Welch  and  Schamberg.     Acute  Infectious  Diseases,  p.  394. 

3  Sloan.     Lancet,  February  14,  1903. 

*  Trujowsky.     Dorpat   Med.    Zeitschrift,   1873,   3. 

5  Hose.     Jahrbuch  f.  I-underlieilk,  Band  xxxix,  p.  S58. 

6  Lettre.     These  de  Paris,  1906-1907,  Xo.  2. 

'  Seitz.     Munch,  med.  Wochensehrift,  1S9S,  No.  3. 

'  Slade-King.     British  Medical  Journal,  December  2.  1905. 


346  SCARLET  FEVER 

In  very  rare  instances  a  second  relapse  may  occur  in  scarlet 
fever,  and  tliree  and  four  relapses  have  been  reported.  Welch  and 
Schamberg^  report  in  detail  a  case  that  had  an  undoubted  second 
relapse.  It  was  interesting  to  note  that  desquamation  followed  each 
attack. 

Second  Attacks. — Second  attacks  of  scarlet  fever  are  rare, 
for  one  attack  protects  the  majority  of  individuals  for  life  from  this 
disease.  There  are,  however,  many  cases  on  record  of  second  and 
a  few  of  third  and  even  fourth  attacks  of  this  disease.  It  is  without 
doubt  true  that  many  of  these  reputed  second  attacks  should  be 
classed  as  relapses  or  are  cases  of  mistaken  diagnosis,  but  there  can 
be  no  doubt,  on  the  other  hand,  that  a  second  or  even  a  third  attack 
of  scarlet  fever  does  rarely  occur.  Mycelius,  quoted  by  Sternberg, 
states  that  he  was  able  to  find  in  the  literature  29  cases  of  second 
attacks  of  scarlet  fever  and  four  cases  in  which  third  attacks  took 
place,  but  no  authentic  cases  of  foiu-  attacks  of  the  disease  were 
recorded.  Willan'  never  encountered  an  instance  of  a  second 
attack  of  scarlet  fever  in  2000  cases  of  the  disease  that  he  attended, 
but,  on  the  other  hand,  Trojanowsky^  states  that  6  per  cent,  of  his 
cases  consisted  of  patients  who  were  ill  of  a  second  attack  of  scarlet 
fever.  Thomas,^  in  his  large  experience,  was  only  sure  of  having 
seen  one  true  second  attack,  and  Henoch^  saw  but  one.  Kinnicutt" 
had  under  his  care  a  boy,  aged  five  years,  w4io  had  two  attacks  of 
the  disease  within  eight  months,  and  Seitz,^  in  an  experience  of  833 
cases,  saw  two  second  attacks,  one  occurring  after  one  year  and 
one  two  years  after  the  primary  attack 

Sequels. — Sequels  of  scarlet  fever,  other  than  those  mentioned, 
usually  represent  a  continuation  of  the  complications  resulting 
from  the  infectious  nature  of  the  disease.  The  mucous  mem- 
brane of  the  throat  and  nose  shows  the  most  persistent  patho- 
logical alteration.  The  ears,  however,  as  already  stated,  are  the 
organs  which  chiefly  suffer.     Next  in  importance  is  the  danger 


1  Welch  and  Scliamberg.     Acute  Contagious  Diseases,  p.  394. 

2  Willan.     Quoted  in  Zieinssen's  Encyclopaedia. 

'  Trojanowsky.     Dorpat  Med.  Zeitschrift,  iii,  1873. 

*  Tliomas.     Ziemssen's  Encyclopedia.  ^  Henoch.     Ibid. 

^  Kinnicutt.     Arch,  of  Pediatrics,  .January,  1908. 

'  Seitz.     Munch,  med.  Woch.,  1898,  No.  8. 


that  following  scarlet  fever  the  kidneys  will  Ix-  \cU  in  a  state  of 
subacute  or  chronic  inflammation. 

Various  cutaneous  (Jiseases,  such  as  eczema,  furunculosis,  sclero- 
derma, and  even  (uberculosis  of  tlicskin,  have  been  noted  as  sequels 
to  an  attack. 

Certain  psychic  disturbances,  such  as  melancholia  and  even 
mania,  may  persist  for  days,  weeks,  or  even  months  after  an  attack 
of  scarlet  fever. 


CHAPTER    III. 

MEASLES. 

Although  measles  is  usually  looked  upon  as  a  comparatively 
harmless  disease  of  infancy  and  childhood,  its  complications  make 
it  a  serious  malady.  The  mortality  of  measles  varies  from  year  to 
year,  hut  the  disease  is  one  of  constant  importance.  The  annual 
average  of  deaths  per  100,000  due  to  measles,from  1901  to  1905,  was 
9.1  in  the  registration  area  of  the  United  States.  In  many  countries, 
notably  Austria,  Belgium,  Hungary,  Spain,  England,  and  Prussia, 
the  mortality  rate  is  much  higher  than  in  America.  The  mortality 
rate  for  the  registration  area  of  the  United  States  census  for  1900 
dispels  any  idea  that  measles  is  a  trivial  affection,  for  we  find  that 
it  caused  12,866  deaths  during  that  year,  whereas  the  mortality 
rate  for  scarlet  fever  was  less  than  half  that  of  measles  for  the  same 
period.  This  difference  is,  of  course,  chiefly  due  to  the  greater 
frequency  of  measles,  but  it  emphasizes  the  fact  that  the  number  of 
deaths  due  to  measles  and  its  complications  is  by  no  means  small. 

Nearly  every  severe  case  of  measles  is  accompanied  by  one  or 
more  complications,  and  sometimes  after  the  patient  recovers  from 
the  initial  illness  he  is  left  with  a  sequel  of  the  disease  which  may 
trouble  him  for  months  or  years.  In  this  respect  cases  seen  in 
private  practice  differ  greatly  from  those  met  with  in  public 
institutions  for  children.  Barthez  and  Sannee^  found,  in  their 
study  of  1521  cases  of  measles,  that  complications  or  sequels  were 
present  in  1044,  and  Haig  Brown'  reports  60  cases  of  this  disease, 
in  48  of  which  there  were  present  complications  or  sequels.  Such 
percentages  as  these  are  far  in  excess  of  those  met  with  in  general 
practice.     The  complications  may  appear  at  any  stage  of  the  dis- 

1  Barthez  and  Sannee.      Traite  cliniq.  et  pratiq.   des  mal.   des   enfants,  Paris,   1891, 
tome  iii,  p.  38. 

2  Haig  Brown.      British  Medical  Journal,  April  10,  1887,  p.  826. 


PJiODUOMAL   RASI/h'S  340 

ease,  und  iml  iiifrcriiictidy  llic  syinploins  of  the  (■<>i]\\)\]c;iiin^  stiite 
may  c-omplclcly  iii;isk  (Jiosc  of  tlic  or-i^inul  Jifrcclion. 

Prodromal  Rashes.—  As  in  jiciuly  iill  (lie  cxMritliciiKitoiis  fcvens, 
the  typiciil  cniplioii  of  iiicmsIcs  is  at  limes  prcccf led  hy  ;ifr'i(|cnt;il 
or  |)ro(h'oiii;i,l  rashes.  Tlicse  rashes  are  not  coinmoii,  hut  f^ecnr 
with  SLilIieient  fretjueney  to  deserve  attention,  paitieularly  as  they 
are  often  responsible  for  mistakes  in  diagnosis.  lioger*  reeords 
5  cases  of  prodromal  rash  of  the  erythematous  type  in  1917  eases 
of  measles.  One  rash  appeared  In  an  infant,  another  in  a  fhiM 
aged  tliree  years,  and  the  remaining  three  eases  oeenrred  in  aduh.s. 
Gerhardt,^  Coniby,^  and  Welch  and  Sehamberg''  all  i*  port  instances 
of  pro(h-omal  rashes,  and  Meredith  Richards''  and  Kolleston"  call 
particular  attention  to  the  danger  of  mistaking  these  early  rashes 
for  the  rash  which  accompanies  typhoid  or  scarlet  fever.  The  pro- 
dromal rashes  of  measles  usually  appear  for  one  to  three  days  before 
the  ordinary  rash,  sometimes  fading  before  the  appearance  of  the 
true  rash,  and  at  other  times  for  a  day  or  two  exist  in  associa- 
tion with  the  characteristic  blotchy  rash  of  the  disease  itself. 
Rolleston  divides  these  prodromal  rashes  into:  (1)  Isolated 
macules.  (2)  Blotchy  erythemata.  (3)  Isolated  papules.  (4j 
Urticarias.  (5)  Circinate  erythemata.  In  addition  to  these 
rashes,  miliary  vesicles  or  sudamina  are  sometimes  seen  in  young 
children  before  the  true  eruption  appears,  but  more  often  when 
the  eruption  is  at  its  acme. 

Chairou^  has  reported  several  epidemics  during  which  miliary 
vesicles  frequently  occmredjand  he  proposed  the  name  of  "sweating 
measles"  for  this  class  of  cases.  Thomas^  is  of  the  opinion  that 
the  prodromal  rash  is  an  expression  of  an  abortive  attempt  to 
produce  the  ordinary  rash. 

In  considering  the  complications  of  measles  it  is  important  to 
remember  that  in  many  instances  it  is  difficult  to  distinguish  the 

'  Roger.     Revue  de  Med.,  April,  1900.     Les  Maladies  Infectieuses,  Paris,  1902. 

2  Gerhardt.     Quoted  by  Thomas  in  Ziemssen's  Cj'clopasdia  of  Medicine,  1897. 

3  Comby.     Traits  des  Maladies  d'Enfance,  Paris,  1S97 

■*  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  492. 
^  Meredith  Richards.     Quarterly  Medical  Journal,  1898,  v,  31. 
"  Rolleston.     British  Medical  Journal,  February  8,  1905. 
'  Chairou.     Quoted  by  Trousseau. 
*  Thomas.     Ziemssen's  Cyclopaedia  of  Medicine,  1897,  ii. 


350  MEASLES 

visceral  lesions  due  directly  to  the  infection  of  measles  from  those 
prodiicci]  by  secondary  infections. 

Complications.^ — "^llie  most  common  complications  of  measles 
are  as  follows:  Disorders  of  tlie  respiratory  tract;  tlisorders  of  the 
digestive  tract;  skin  complications. 

Although  bronchopneumonia  is  the  most  important  of  the  respira- 
tory complications,  it  is  appropriate,  before  discussing  its  character- 
istics as  such,  to  speak  of  the  lesions  often  met  with  in  tlie  upper 
respiratory  passages.  As  the  catarrhal  symptoms  are  so  prominent,, 
it  is  to  be  expected  that  the  mucous  membranes  of  the  respiratory 
tract  would  suffer  during  or  after  the  disease.  Thus,  we  find  that 
catarrhal  laryngitis  is  so  constantly  present  in  measles  that  it  can 
scarcely  be  looked  upon  as  a  complication.  Holt^  states  that 
severe  catarrhal  laryngitis  is  present  in  over  10  per  cent,  of  all  cases 
of  measles.  Ulcerative  laryngitis  appears  in  a  certain  limited 
number  of  severe  cases.  The  inflammation  leads  to  necrosis  of 
the  mucous  and  submucous  tissues  and  the  vocal  cords  in  these 
cases  are  commonly  involved  in  the  destructive  process.  Barthez 
and  Rilliet^  found  ulceration  of  the  larynx  in  nearly  50  per  cent, 
of  the  cases  of  measles  which  came  to  autopsy,  and  Gerhard t,* 
who  studied  these  ulcerations  of  the  larynx  during  life,  came  to  the 
conclusion  that  they  occurred  very  much  more  commonly  than  is 
usually  thought.  The  superficial  ulceration  gives  rise  to  a  dry 
cough,  accompanied  by  severe  pain,  which  is  made  worse  by 
swallowing  or  speaking. 

Membranous  laryngitis  is  a  very  fatal  form  of  the  disease  which) 
is  produced  by  the  action  of  the  streptococcus,  the  diphtheria 
bacillus,  and  possibly  other  organisms.  Holt  found  that  35  cases 
of  membranous  laryngitis  occurred  in  283  cases  of  measles,  but  is 
confident  that  the  complication  occurs  much  more  frequently  than 
this  in  epidemics  in  institutions.  Granlou*  found  in  his  work  at 
I'Hospice  des  Enfants  Assistis  that  in  1633  cases  of  measles,, 
membranous  laryngitis  occurred  235  times,  and  of  these  cases,  218 
were  fatal,  while  among  the  remaining  1398  cases  only  388  died. 

1  Holt.     Infancy  and  Childhood,  p.  967. 

-  Barthez  and  Killiet.     Traitd  cliniq.  de  prat.  d.  mal.  d.  enfants,  Paris,  1891,  t.  iii,p.38_ 

'  Gerhardt.     Lehrbuch  der  Kinderkrankheiten,  p.  63. 

*  Granlou.     La  rougeole  I'hospice  des  enfants,  Paris,  1892. 


P ULMONA  It  V   CO M/'/J (J A  770 A'-S'  .'jo  J 

These  statistics  show  what  jui  cxirciix-ly  (lan^rcroiis  coinijlif  ation 
m('inl)raiioiis  laryiioilis  is. 

AIth()ii|j;li  th(T(!  has  cxislcd,  in  (he  past,  a  (|in'crf':if(r  ol'  o^Ainon 
as  to  the  cause  of  incinhraiioiis  laryngitis,  it  is  prohahly  true  that  in 
the  great  majority  ol'  cases  pyogenic  cocci  are  responsihle  for  tli<; 
condition,  bnt  it  is  to  be  remembered  that  the  diagnosis  Ix-tween 
true  laryngciil  diphtheria  and  membranous  laryngitis  com}>h'cating 
measles  can  only  be  made  by  a  bacteriological  examination.  When 
di[)htheria  complicates  measles  it  is  likely  to  make  its  appearance 
late  in  the  disease,  while  membranous  laryngitis  usually  apj>ear.s 
early  or  at  the  height  of  the  malady, 

De  Cerlant^  records  a  case  of  obstructive  dyspnoea  which  ap- 
peared before  the  rash  of  measles  developed.  In  this  instance  the 
symptoms  of  obstruction  were  in  evidence  throughout  the  disease. 
Sevestre  and  Burmus^  have  reported  a  similar  case  in  which  the 
obstructive  symptoms  were  so  intense  that  it  was  found  necessary 
to  intubate.  Welch  and  Schamberg^  state  that  a  number  of  such 
cases  have  been  seen  by  them,  many  of  which  it  was  found  necessary 
to  intubate,  and  they  add  the  significant  statement  that,  in  their 
experience,  all  the  patients  intubated  for  this  condition  died. 

True  diphtheria  occasionally  complicates  measles,  but  many  of 
the  cases  reported  are  undoubtedly  instances  of  membranous 
laryngitis  due  to  pyogenic  organisms.  Adriance,^  however,  has 
reported  an  epidemic  of  96  cases  of  measles  in  the  Nursery  and 
Child's  Hospital  of  New  York,  36  cases  of  which  were  complicated 
by  diphtheria.     Four  of  these  36  cases  proved  fatal. 

Necrosis  of  the  laryngeal  cartilages  and  oedema  of  the  glottis  are 
rare  complications,  and  are  usually  seen  dm-ing  epidemics  of  the 
disease  occurring  in  ill-nourished  children  such  as  are  found  in 
asylums  and  charity  hospitals. 

Pulmonary  Complications. — The  trachea  and  bronchial  tubes 
are  always  involved  in  the  catarrhal  process  of  measles,  and  during 
the  extension  of  the  inflammation  tlii'ough  the  air  passages  the 
complication  may  assume  a  serious  aspect.     The  most  frequent 

1  De  Cerlant.     Gaz.  Hebdomadaire  des  Sciences  Medicales  de  Bordeaux,  Maj"  8,  1904. 

2  Sevestre  and  Burmus.     Archives  de  M^decine  des  Enfants,  1S99,  No.  2,  p.  65. 
5  Welch  and  Schamberg.     Log.  cit.,  p.  502. 

*  Adriance.     Archives  of  Pediatrics,  February,  1900. 


352  MEASLES 

and  by  far  the  most  important  C()iiij)lication  of  measles  is  broncho- 
pnenmonia. 

BRONCHOPNErMONiA. — This  is  not  only  the  most  frequent  but 
also  the  most  fatal  (•t)ni])lieation  of  measles.  Its  frequency  varies 
very  much  in  different  epidemics,  and  it  is  far  more  common  in 
foundling  asylums  and  similar  institutions  than  in  private  piactice. 
Holt*  states  that  during  two  epidemics  of  measles  in  the  Nursery  and 
Child's  Hospital,  affecting  about  300  cases,  bronchopneumonia 
occurred  in  about  40  per  cent.  These  children  were  nearly  all 
under  three  years  of  age,  and  therefore  more  susceptible  than  older 
children.  Seventy  per  cent,  of  those  affected  with  pneumonia 
died.  Holt  agrees  with  Henoch,  who  believes  that  a  certain  amount 
of  pneumonia  is  fountl  in  every  fatal  case  of  measles.  Bartels^ 
saw  68  cases  of  bronchopneumonia  among  573  cases  of  measles, 
that  is,  11.9  per  cent.  Ziemssen  and  Kabler^  reported  50  attacks 
of  this  complication  in  311  cases  of  measles,  or  16.1  per  cent., 
while  Embden^  found  only  27  cases  of  pneumonia  in  4(51  cases,  or 
5.9  per  cent.  Landis,^  in  his  analysis  of  457  cases  of  measles  at 
the  Philadelphia  Hospital,  found  54  complicated  with  broncho- 
pneumonia, and  of  this  number  43  proved  fatal  (79  per  cent.). 
It  is  a  noteworthy  fact  that  bronchopneumonia  usually  manifests 
itself  when  the  eruption  begins  to  fade  rather  than  during  the  course 
of  the  malady,  and  it  may  be  delayed  for  some  days  after  the  dis- 
appearance of  the  eruption.  When  measles  is  complicated  by  a 
pneumonia,  particularly  of  the  bronchopneumonic  type,  the  tem- 
perature does  not  fall  after  the  disappearance  of  the  rash,  but  instead 
usually  rises  to  a  point  higher  than  before,  and  with  the  increase  in 
temperature  there  is  noted  a  rapidity  of  pulse  and  in  the  respiratory 
rate,  with  cough.  Percussion  will  reveal  impairment  of  resonance 
over  areas  of  the  lung,  the  breath  sounds  are  of  the  bronchovesicular 
type,  and  fine  and  coarse  moist  rales  are  often  clearly  heard. 

Lobar  pneumonia  is  a  much  less  frequent  complication  of 
measles  than  the  catarrhal  form,  and  when  it  occurs  is  usually  met 

1  Holt.     Loc.  cit.,  p.  966. 

*  Bartelg.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  503. 

^  Ziemssen  and  Kabler.     Griefswalder  med.  Beitriige,  1861,  Band  ii,  S.  117. 

*  Embden.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  503. 
'  Landis.     American  Medicine,  1908,  viii,  234. 


rULMONAUY   COM  I' Lie  AT  IONS  :j53 

wli;li  as  a  complication  in  an  ;ulult  or  in  cliildicn  iic;ir-  pnltcrty. 
Stcdcrns*  lias  r(!j)ortc(]  5  cases  of  this  coiiiplicatioii  in  a  scries  of 
322  cases  of  measles. 

Bernardy^  reports  his  very  unusual  experience  in  caring  for  12 
cases  of  lobar  pneumonia  in  a  series  of  160  cases  of  measles,  and 
Bottomley'  states  that  he  has  met  with  13  cases  of  this  complica- 
tion in  treating  a  large  number  of  cases  of  this  disease. 

Pleurisy,  with  or  without  effusion,  is  a  rare  complication  of 
measles.  When  encountered  this  complication  is  more  likely  to 
prove  to  be  tuberculous  than  to  be  a  simple  pleurisy.  Fiirbringer^ 
has  called  attention  to  the  occasional  development  of  a  primary 
pleurisy,  usually  followed  by  effusion  purulent  in  character,  early 
in  the  course  of  measles.  He  has  observefl  a  number  of  sucli  cases, 
and  believes  that  the  effusion  is  purulent  from  its  onset.  Mery 
and  Lorrain^  report  a  fatal  case  of  measles  complicated  by  a  large 
pleural  effusion.  Roger"  had  under  his  care  a  child,  aged  five  years, 
who  developed  a  purulent  pleurisy  during  measles,  and  Guttceit^ 
has  recorded  an  unusual  epidemic  of  measles  in  which  hydrothorax 
was  a  frequent  complication,  and  states  that  nearly  all  the  patients 
who  developed  this  complication  died.  Cornil  and  Babes*  and 
SteibeF  have  also  seen  cases  of  measles  in  which  the  pleura  was 
involved.  Ballico^"  reports  a  case  in  which  a  hemorrhagic  pleurisy 
occurred  during  measles. 

Empyema  during  and  following  measles  is  almost  as  frequent 
as  pleurisy,  for,  as  above  stated,  the  purulent  effusions  are  prone 
to  become  purulent.  Roger  and  Fiirbinger  have  both  reported 
instances  of  this  complication. 

Pulmonary  tuberculosis  so  frequently  follows  an  attack  of 
measles  that  in  a  certain  proportion  of  cases  tuberculosis  may  be 
looked  upon  as  a  direct  sequel.     Whether  there  has  been  present  a 

1  Stefferns.     Deutsche  Arcliiv  f.  klin.  1899,  Ixii. 

2  Bernardy.     Ann.  Gynecology  and  Pediatrics,  July,  1S99,  p.  618. 
8  Bottomley.     British  Medical  Journal,  February  4,  1905. 

^  Fiirbringer.     Quoted  by  von  Jurgensen  in  Eulenberg's  Encyclopedia,  xii,  559. 
'  Mery  and  Lorrain.     Anat.  de  Paris,  March,  1897. 
*  Roger.     Les  Maladies  Infectieuses. 

^  Guttceit.     Quoted  by  Houl,  Wiener  klin.  Rund.,  1S97,  ii,  833. 
8  Cornil  and  Babes.      Quoted  by  Dawson  WiUiams,  Glasgow,  1896. 
^  Steibel.     Quoted  by  Thomas  in  Ziemssen's  Cyclopedia. 
1°  Ballico.     Rendic.  d.  Assn.  Med.  Chir.  de  Parma,  1905,  vi,  139. 
23 


354  MEASLES 

latent  focus  of  tuberculosis  in  the  lung  before  the  attack  of  measles 
is  often  tlilHcult  to  deternn'ne,  but  in  many  cases  (his  is  undoubtedly 
the  case,  and  following  the  exhaustion  of  the  j)a(iciit  from  the 
acute  disease  the  tuberculous  jirocess  finds  little  resistance  in  the 
pulmonary  tissues.  Tuberculosis  may  develop  in  an  area  of 
bronchopneumonia  which  remains  unresolved. 

Gangrene  of  the  lungs  following  measles  was  met  with  by 
Barthez  and  Rilliet^  in  four  instances.  Steiner  and  Neureutter"  have 
also  met  with  this  complication  twice  in  their  experience.  Aleiy  and 
Lorrain^  report  the  case  of  a  three-year-old  child  who  died  on  (lie 
seventh  day  of  a  severe  attack  of  measles,  and  at  autopsy  the  entire 
lower  lobe  of  the  lung  was  gangrenous.  Ruhrah^  observed  four 
cases  of  gangrene  of  the  lung  in  one  epidemic  of  measles,  but  this 
is  a  very  unusual  experience.  In  all  cases  the  gangrene  of  the  lung 
is  secondary  to  a  severe  l)ronchopneumonia. 

Disorders  of  the  Digestive  Tract. — The  mucous  membrane 
of  the  gastro-intestinal  tract  is  always  involved  to  a  greater  or  less 
degree  during  measles,  and  the  complications  may  become,  particu- 
larly among  badly  nourishetl  children,  second  in  importance  only 
to  the  pulmonary  complications. 

Catarrhal  stomatitis  is  always  present  in  severe  cases  of  measles 
and  in  a  great  number  of  the  mild  cases. 

Ulcerative  stomatitis  is  by  no  means  infrequent,  particularly 
during  epidemics  of  the  disease  among  children  in  crowded  insti- 
tutions. The  usual  location  is  in  the  buccogingival  furrow.  The 
condition  is  characterized  by  the  formation  of  small  patches  covered 
with  necrotic  epithelium. 

Gangrenous  stomatitis  or  noma  is  fortunately  a  rare  complica- 
tion or  sequel,  but  more  often  follows  measles  than  any  other  disease. 
It  usually  occurs  during  the  course  of  a  severe  type  of  the  disease 
in  a  badly  nourished  child,  particularly  in  those  children  living  in 
crowded  institutions  or  with  bad  surroundings.  The  condition  is 
a  most  distressing  one  to  treat,  and  is  fatal  in  the  great  majority 
of  cases.    The  most  frequent  site  for  noma  is  in  the  furrow  between 

'  Barthez  and  Rilliet.     Traits  cliniq.  et  pratiq.  des  mal.  des  enfants,  Paris,  1891. 
2  Steiner  and  Neureutter.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  505. 
'  Mery  and  Lorrain.     Anat.  de  Paris,  March,  1897. 
*  Ruhrah.     In  Nothnagel's  System,  Measles. 


j)JS()UJji:h's  ()!<'  77//';  i)i<:h:s'i'i\  I':  tuact  wr^'i 

the  cheek  und  teeth,  next  hi  imjijeney  in  tlie  nf>s,  |);iiti(iil;irly  the 
h)wer  hp,  und  rarely  the  arcli  of  the  soft  pjihilc  In  I  Ik-  Ki  cases 
rep()rt(!(l  hy  Hhnner  and  MaeKarhmd'  llic  nioiilli  nlonc  \\;i^  ;i fleeted 
in  4,  tlie  inondi  and  e;ir  in  W,  tlic  nioiilli,  e;ir,  iind  vul\;i.  in  '■'>,  (Ik- 
vnlva  alone  in  .'5,  iind  the  reetnrn  in  '.'>.  Ilolt^  lias  rej>orU'd  7 
instances  in  whicii  noma,  attacked  the  external  e;ir.  Wejiver  and 
'rniniiclid"'  liiive  reviewed  tite  litcriitnrc  of  lliis  siihjcci  mo  :(  (Iioi- 
onjijiily  in  re[)ortino-  a  case  ol"  noma  complicatiiif^  scarh't  fever. 
ToLirdes,*  who  analyzed  98  cases  of  noma,  found  that  in  39  of 
this  number  the  condition  comphcated  an  attack  of  measles,  and 
Krahm""'  found  that  55  of  133  cases  of  noma  also  occurred  during 
measles.  Hildehrandt  and  Perthes"  have  collected  133  cases  of 
noma,  and  of  these  cases,  53  accompanied  an  attack  of  measles. 
Blumer  and  MacFarland  have  reported  an  interesting  epidemic  of 
measles  that  occurred  among  the  inmates  of  an  orphan  asylum, 
in  which,  of  the  173  children  suffering  from  the  disease,  16  devel- 
oped noma.  Crowdon,  Place,  and  Brown''  report  a  similar  epidemic 
of  measles,  in  which  there  were  46  cases  of  ulcerative  stomatitis  but 
only  6  of  gangrenous  stomatitis  or  noma. 

Landis,^  who  studied  the  records  of  457  cases  of  measles  at 
the  Philadelphia  Hospital,  found  that  there  were  only  records  of 
6  cases  having  developed  noma,  and  that  of  these  6,  5  died.  We 
find  that  among  the  6364  children  admitted  to  the  East  London 
Hospital,  only  5  had  noma,  and  among  13,000  children  admitted 
to  the  Great  Ormond  Street  Hospital  for  children,  only  6  cases 
were  seen,  which  gives  one  some  idea  as  to  its  rarity.  Noma  is 
not  infrequently  accompanied  by  gangrenous  processes  elsewhere 
in  the  body,  as  gangrene  of  the  lung,  larynx,  oesophagus,  and 
stomach. 

In  four  cases  of  noma  reported  by  Barthez  and  Rilliet"  in  their 
study  of  20  cases  of  this  condition,  they  found  gangrene  of  the  lung. 

1  Blumer  and  MacFarland.     American  Journal  of  the  Medical  Sciences,  1901,  cxxii,  527. 

-  Holt.     Diseases  of  Infancy  and  Childhood,  p.  968. 

3  Weaver  and  Tunnicliff.     Journal  of  the  Infectious  Diseases,  January,  1907. 

^  Tourdes.     These  de  Strassburg. 

'  Krahm.     Quoted  by  Crowdon,  Place,  and  Brovm,  loc.  cit. 

^  Hildebrandt  and  Perthes.     Dissertation,  Berlin,  1873. 

'  Crowdon,  Place,  and  Brown.     Boston  Medical  and  Surgical  Journal.  April  15,  1909. 

'  Landis.     American  Medicine,  1908,  viii,  23-1.  ^  Barthez  and  Rilliet.     Loc.  cit. 


35G  MEASLES 

Move  than  one  attack  of  noma  is  a  verv  unusual  condition,  but 
Berthe/  writing  in  1754,  stated  that  he  saw  a  child  afflicted  with  this 
condition  twice,  and  ZiegkM'- reports  two  cases  of  noma  that  rehipsed. 

Noma  has  a  particuhuly  liigh  deatli  rate  for  several  reasons:  (1) 
The  condition  only  develops  in  poorly  nourished  children  that  do 
not  have  sufiicient  food  and  are  deprived  of  fresh  air.  (2)  The 
condition  usually  develops  during  or  after  severe  attacks  of  the 
primary  disease,  and  is  in  many  cases  accompanied  by  a  severe 
bronchopneumonia.  Tourdes^  states  that  of  00  cases  of  noma 
seen  by  l^aron  and  Taupin,  everyone  died.  Tourdes  also  collected 
information  concerning  239  other  cases  of  noma,  and  found  that  of 
this  number,  176  died,  giving  a  mortality  of  73  per  cent. 

Nine  of  the  14  cases  seen  by  Mayr^  died,  as  did  10  of  the  IS  cases 
collected  by  Gierke.  Springer^  reports  23  cases  with  2  recoveries, 
giving  a  mortality  rate  of  90.5  per  cent.  Of  this  last  series  of  cases, 
10  were  operated  upon  and  14  died,  a  mortality  of  87.5  per  cent., 
while  of  the  7  not  operated  upon,  all  died.  Of  the  entire  number 
(970)  of  cases  of  noma  collected  by  Weaver  and  TunniclifT" 
from  the  literature  of  the  subject  and  their  own  experience,  7()0 
died  and  210  recovered,  giving  a  mortality  rate  of  77,8  per  cent. 
As  already  stated,  when  death  occurs  during  the  course  of  noma 
the  fatal  termination  is  often  actually  caused  by  an  accompanying 
bronchopneumonia.  Thus  it  was  found  in  one  series  of  03  fatal 
cases  of  noma  that  bronchopneumonia  was  present  in  58,  and  in 
21  cases  of  noma  reported  by  Barthez  and  Rilliet,^  pneumonia 
was  absent  in  but  two. 

Tonsillitis  during  measles  is  occasionally  noted,  and  when  the 
tonsils  are  affected  membranous  patches  not  infrequently  are  pres- 
ent which  are  due  to  infection  of  the  inflamed  mucous  membrane 
by  pyogenic  bacteria  which  are  usually  streptococcic  or  staphylo- 
coccic in  their  nature.  The  Klebs-Loeffler  bacillus  is  rarely  met 
with  as  a  cause  of  this  condition. 

'  Berthe.     Quoted  by  Weaver  and  Tuiinicliff,  loc.  cit. 

^  Ziegler.     Miinch.  med.  Woch.,  1892,  xxxix,  10". 

'  Tourdes.     Loc.  cit. 

■•  Mayr.     Ztsch.  kais.  kou.  Gesellsch.  der  Aerzte  zu  Wien,  1852,  p.  201. 

*  Springer.     .Tahrbuch  f.  Kinderheilk,  1904,  Ix.  613. 

*  Weaver  and  Tunnicliff.     Loc.  cit. 
'  Barthez  and  Rilliet.     Loc.  cit. 


DfSORDfJRS  OF  T/ff'J  DldlC^TIV E  THACT  y^TyJ 

RetROPHARYNGKaf.  aijsckss  ofnurinf^^  ;i.s  u  cornpliojitioii  ur 
sequel  is  extremely  nire,  and  wlicii  it,  flcvclop.s  i.s  nearly  always  a 
sequel  of  pyogenic  infection  of  the  [)l)aryn^('al  wall. 

Parotitis  is  another  rare  eornplieation  or  sequel.  I'ucfi'  has 
reported  a  case,  and  there  have  been  occasionally  seen  cases  in 
which  mumps  com[)Iicated  mea.sles.  Thomas^  states  that  Ficht- 
bauer,  Thore,  Kismann,  Biifalini,  and  Battersey  have  all  .seen  cases 
of  parotitis  accompanying  measles,  and  that  Scidl,  Schultze,  and 
Kellner  have  met  with  this  condition  as  a  scfjuel  to  this  disease. 

The  stomach  and  intestines  are  rarely  affected  In  the  sense 
that  they  develop  definite  or  characteristic  lesions,  but  vomiting  and 
diarrhoea  during  the  course  of  measles  are  commonly  met  with. 
Obstinate  vomiting  due  to  an  acute  catarrhal  gastritis  is  not  com- 
mon, but  when  it  occurs  it  is  often  a  dangerous  .symptom.  Diarrha.-a 
is  a  frequent  and  in  many  cases  a  severe  symptom,  being  caused  by  a 
catarrhal  conditionof  thebowel.  This  symptom  may  vary  in  severity 
from  a  slight  catari  hal  enteritis,  which  is  common,  to  a  severe  and, 
at  times,  fatal  enterocolitis,  which  is  rare.  This  symptom,  when 
it  develops  in  an  infant  or  young  child  during  an  attack  of  measles, 
and  particularly  during  the  summer  months,  is  likely  to  be  a  serious 
complication.  Welch  and  Schamberg^  state  that  cases  are  on 
record  in  which  diarrhoea  during  an  attack  of  measles  in  adult  life 
has  proved  fatal.  One  of  us  (Beardsley)  had  under  his  care  a 
young  man,  aged  twenty-six  years,  who  suffered  from  a  very  severe 
attack  of  measles,  at  the  height  of  which  diarrhoea  appeared  as  a 
prominent  and  most  troublesome  symptom.  The  prostration 
in  this  case  was  very  marked,  although  the  temperature  after 
the  appearance  of  the  rash  was  at  no  time  high.  On  the  second 
day  of  the  diarrhoea  a  small  quantity  of  blood  was  passed  by  the 
bowel  with  a  quantity  of  foul-smelling  mucus.  Convalescence  in 
this  case  was  much  delayed,  and  the  patient  was  unable  to  resume 
his  work  for  four  weeks  after  he  left  his  bed.  Diarrhoea  is  much 
more  frequent  in  certain  epidemics  than  in  others.  "Willischanin* 
studied  and  reported  an  epidemic  of  measles  m  a  school  for  girls, 

1  Pucci.     Gazz.  d.  osp.  del.  clin.,  1896,  x^-ii,  291. 

-  Thomas.     In  von  Ziemssen's  Cyclopaedia. 

3  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  506. 

^  Willischanin.     St.  Petersburger  med.  Wochen.,  December  4,  1893. 


358  MEASLES 

in  which  10  of  tho  '^0  patients  had  a  scvciv  diarrhoea  chn-jni^ 
convalescence. 

Appendicitis  occurs  with  no  greater  frequency  durino;  an  attack 
of  measles  than  in  ordinary  life.  This  is  illustrated  by  the  fact  that 
tlie  only  case  we  have  been  able  to  find  in  the  literature  of  the 
suljject  is  oiu-  rc})ortcd  bv  ]\ren(i;us.^ 

Skin  complications  durino-  measles  are  of  importance.  We 
have  already  mentioned  the  prodromal  and  complicating  rashes 
(p.  349). 

Facial  herpes  is  sometimes  seen  during  the  early  stages  of  measles, 
and  may  persist  until  convalescence.  Rarely  herpetic  spots  appear 
late  in  the  disease.  This  eiuption  ^vas  noted  in  five  of  Landis'' 
457  cases. 

Urticarial  eruptions  are  rare,  but  are  sometimes  seen  dining  the 
prodromal  stage  of  measles  or  even  in  the  well-developed  stage 
of  the  disease.  Claus^  has  reported  two  cases  which  appeared 
during  the  stage  of  incubation. 

Bullous  eruptions  during  measles  have  been  reported  by  many 
observers,  but  the  condition  is  infrequent.  Among  those  reporting 
cases  which  showed  bulLi?  are  Krieg,^  Loschner,''  Henoch,"  Steiner/ 
Du  Castel,*^  Baginski,"  and  Romberg.^"  Steiner  saw  four  cases  in  the 
same  family.  The  blebs,  which  appeared  in  crops,  varied  in  size 
from  that  of  a  pea  to  that  of  a  pigeon's  egg,  attacked  both  the  skin 
and  mucous  membranes,  and  w'ere  frequently  accompanied  by 
fever. 

Impetigo  is  occasionally  observed  during  the  convalescing  period 
of  measles. 

Eczema  sometimes  occurs  after  an  attack  of  measles,  and  ery- 
thema nodosum  is  rarely  seen. 

Disseminated  tuberculosis  of  the  skin  following  this  disease  has 

'  Mengus.     Arch.  M^d.  de  Angen.,  1905,  ii,  756. 
2  Landis.     American  Medicine,  loc.  cit. 

'  Claus.     Jahrbuch  f.  Kinderheilk.  u.  Phys.  Erzieh.,  June,  1894. 
*  Krieg.     Cst.  Jahrbuch,  184.3,  p.  219. 

^  Loschner.     Quoted  by  Welch  and  Schamberg,  loc.  cit.  p.  .508. 
"  Henoch.     Berliner  klin.  Wochenschrift.,  1882,  p.  19.3. 
'  Steiner.     Jalirbuch  f.  Kinderh.,  new  series,  vii,  346. 
8  Du  Castel.      Rev.  gdn.  de  clin.  et  de  thdra.,  Paris,  1897,  ii,  609. 
'  Baginski.     Archiv  f.  Kinderh.,  1901,  Band  xxviii,  Heft  1  and  2. 
"I  Romberg.     Quoted  by  Henoch,  loc.  cit. 


>S'A7yV  COMI'LICATIOSS  •/,:><) 

Ix'cii  iiolcd  hy  iiiiiny  vvrllcr'.'-:,  iiiiioii<^-  llicin  M;i(l(i)(|,'  II;ill,^ 
Wliitiikcr,''  l^>,sclicricli,'  I)ii  ( 'iisld,''  IIjiiisIiuIUt,''  jmkI  Afliiinvjii.'' 
'J'liis  condition  is  usually  widely  distributed  over  Uu;  surfiiec  of  dir- 
patient,  and  affects  the  face  of  the  extremities  as  well  as  Uh-  (ruul.. 

Psoriasis  has  also  been  known  to  make  its  first  aj^fjearunce 
shortly  after  an  attack  of  measles,  the  primary  disease  in  this  instance 
probably  actin^^  as  the  exeitiiif^  cause  in  a  predisposed  subject 

Miliary  vesicles  are  rarely  seen  durin<i;  nii  attiu-k  of  measles,  but 
sometimes  occur  in  younn-  subjects  on  those  p(;rtions  of  the  iKKly 
which  are  well  supplied  by  sudoriparous  glands,  being  particularly 
in  evidence  on  those  portions  of  the  body  which  are  well  covered 
with  the  rash. 

Suhciifaneous  emphysema  has  been  observed  as  a  complication 
of  measles,  but  is  rare.  It  has  resulted  from  paroxysms  of  coughing 
in  young  children,  particularly  when  the  attack  of  measles  was 
complicated  by  whooping  cough.  Swoboda,*  Heijer,"  Piet,'" 
Varnali,"  Berry,''  Kelly,"'  Felsenthal,"  and  ralleske"''  have  all  met 
with  this  complication  during  measles.  Varnali's  patient  was  a 
child,  aged  ten  years,  who  had  suffered  from  whooping  cough  eight 
months  previously. 

Purpura  during  measles  is  sometimes  met  with,  the  two  ei  uptions 
remaining  distinct  throughout  the  attack,  and  occasionally  attacks 
of  purpura  fulminans  are  seen  that  are  extremely  dangerous  to 
life.  Pucci,""  Jackson,"^  Masarei,'^  and  Gley"  have  each  reported 
instances  of  this  character. 

1  Macleod.     Proc.  Royal  Soc.  of  Med.,  London,  1907-1908. 

2  Hall.     British  Medical  Journal,  September  28,  1901. 

3  Whitaker.     Jour.  Cutaneous  Disease,  inc.  Sj^jh.,  1908,  xxvi,  461. 

4  Escherich.     Mitt.  d.  Gesellsch.  f.  inn.  Med.,  1905,  iv,  48. 

6  Du  Castel.     Rev.  g^n.  de  clin.  et  de  Tht^rap.,  Paris,  1897,  ii,  609. 

6  Haushalter.     Annal.  de  Dermatologie  et  de  SjTsh.,  1898,  tome  ix.  No.  5,  p.  45.5. 

7  Adamson.     Brit.  Jour,  of  Dermat.,  1899,  p.  20. 

8  Swoboda.     Mitt.  d.  Gesellsch.  f.  innere  med.  u.  Kinderh.  in  Wien,  1905,  iv,  172. 
^  Heijer.     Nederl,  Tijdschr.  v.  Geneesk.,  Amst.,  1905,  ii,  41,  p.  1010. 

'0  Piet.     Jour,  de  Soc.  de  Med.  de  Lille,  1905,  ii,  272. 

"  Varnali.     Revue  Mensuelle  des  Maladies  de  I'Enfance,  May,  1894,  p.  266. 

1-  Berry.     British  Medical  Journal,  February  27,  1899. 

"  Kelly.     Therapeutic  Gaz.,  January,  1891. 

»  Felsenthal.     Archiv  f.  Kinderh.,  1891,  Band  xiv,  Heft  1  and  2. 

15  Palleske.     Deut.  med.  Woch.,  1898,  xxiv.  255. 

16  Fucci.     Gazz.  d.  osp.  del.  clin.,  1896,  xvii,  291. 
1"  Jackson.     Arch,  of  Pediat.,  1890,  vii,  951. 

'5  Masarei.     Quoted  by  Thomas  in  Archiv  der  Heilkunde.  1867. 
1'  Gley.     Quoted  by  Thomas  in  Archiv  der  Heilkunde,  1867. 


300  MEASLES 

The  above  coiuHtions  are  to  be  distinguished  from  hemorrhagic 
measles,  of  which  there  are  two  chief  types  between  the  extremes  of 
which  all  grades  of  severitv  exist.  The  mild  form  of  hemorrhagic 
measles  is  not  very  uncommon.  Holt^  found  it  in  5  per  cent,  of 
all  cases, and  Edgar,'dm-ing  an  epidemic  of  423  cases, saw  200  cases, 
or  47  per  cent.  Its  frequency,  however,  varies  much  in  different 
epidemics.  The  hemorrhagic  eruption  is  bluish  or  purplish  in 
color,  and  does  not  disappear  on  pressure.  The  lower  extremities 
may  alone  show  this  hemorrhagic  eruption,  or  it  may  be  generally 
disturbed.  There  is  usually  bleeding  from  the  various  mucous 
membranes.  Sometimes  this  bleeding  is  slight  in  amount  and  at 
other  times  it  is  free.  In  well-nourished  subjects  the  presence  of 
the  hemorrhagic  eruption  does  not  greatly  influence  the  mortality, 
but  in  weakened,  anaemic  children  this  form  of  the  disease  is  some- 
times fatal. 

The  malignant  form  of  hemorrhagic  measles  was  far  more 
common  in  the  earlier  centuries  and  is  now  very  infrequently  met 
with.  In  this  type  of  the  disease  the  prognosis  is  extremely  bad, 
and  the  patient  may  die  within  forty-eight  hours  of  the  onset  of 
the  hemorrhagic  symptoms. 

Gangrenous  processes  in  ihe  skin,  sometimes  associated  with 
noma  and  sometimes  appearing  alone,  have  been  noted  for  many 
years  as  complications  of  measles.  Moynier^  observed  (3  cases. 
In  4  cases  the  vulva  was  attacked,  two  of  the  patients  dying. 
The  skin  of  the  abdomen  was  affected  once,  the  skin  of  the  face 
twice,  and  the  skin  of  the  arm  and  buttock  each  once. 

Blumer  and  IMacFarland,*  Guirke,^  Mayr,"  and  Wood^  have  called 
attention  to  the  occurrence  of  gangrene  of  the  genitals  without 
gangrene  of  the  face,  while  the  frequency  of  associated  gangrenous 
areas  on  the  face  and  genitals  have  been  noted  by  Bouchut,*  Orth,* 


'  Holt.     Diseases  of  Infancy  and  Cliildhood,  p.  915. 

^  Edgar.     Can.  Med.  Record,  December,  1892. 

'  Moynier.     Des  accidents  de  la  rougeole,  etc.,  Metz,  18G0. 

♦  Blumer  and  MacFarland.     American  Journal  of  the  Medical  Sciences,  1901,  cxxii,  527. 

5  Guirke.     Jahrbuch.  f.  Kinderheilk.,  1868,  i,  267. 

°  Mayr.     Ztsch.  kais.  kon.  Gesellsch.  der  Aerzt  zu  Wien,  1852,  p.  201. 

'  Wood.     Medico-Chirurg.  Trans.,  1816,  vii,  84. 

'  Bouchut.     Handbuch.  der  Kinderkrank.,  Wurzburg,  1862,  p.  685. 

«  Orth.     Lehrbuch  d.  spec.  path.  Anat.,  1887,  i,  613. 


a/'JNiTO-u/i/NA  It  V  COM  rue  A  TiONS  :>r,  1 

Richter/  and  Blumcrand  MacFarlurid.''  AnfoniHfi^  has  reported 
pjangrene  of  the  skin  of  tlic  gciiiUil  region  jissociatcd  witli  tli.'if  (jf  (lie 
gluteal  and  ioi^iiinal  rcnion,  ;iiid  M;ijiiiia,''  I'crriri,'  Wiiridfr," 
Tlioiiias/ Kiclilioi'st,*^  I  Icllcnrii,"  ;iihI  rdliccs  liavc  r<-\>(>rU:(\  siinihir 
cases. 

lite  lymphalJc  glaiuLs  arc  always  slif^htly  (-nlar^cd.  Jn  some 
cases  this  enlargement  may  become  very  marked,  particularly  in  the 
cervical  and  submaxillary  regions.  Abscesses  are  partifiihirly 
frequent  in  the  lymphtitic  glands  and  other  tissues  of  the  sul>- 
maxillary  region.  The  suppurative  process  does  not  cause  trouble, 
as  a  rule,  until  some  weeks  after  convalescence  (see  sequels,  p.  372) 
from  the  acute  disease,  and  is  therefore  rarely  recorded  as  a  com- 
plication or  even  as  a  sequel  of  measles.  One  of  us  (Beardsley) 
has  seen  sixteen  such  cases  at  the  out-patient  department  of  the 
Starr  Centre  Dispensary  during  the  last  six  months.  In  some  cases 
the  glandular  enlargement  may  persist  for  a  long  time,  and  may 
terminate  in  a  tuberculous  infection,  while  in  other  cases  the  glands 
break  down  and  suppurate,  as  described  by  Gregory  and  Rilliet.^** 

Genito-urinary  Complications. — The  genito-urinary  complica- 
tions of  measles,  although,  as  a  rule,  not  severe,  are  neverthe- 
less of  some  importance.  Albuminuria  during  the  febrile  period  is 
as  common  as  it  is  in  all  the  acute  febrile  diseases.  The  junior 
author  examined  the  urine  of  20  cases  of  measles  daily,  and  found 
that  of  this  number  16  showed  albumin  at  some  time  during  the 
course  of  the  disease,  and  m  4  cases  the  urine  contained  casts. 
In  none  of  the  cases  was  albumin  present  ten  days  after  convales- 
cence, but  in  one  case  casts  were  found  for  a  period  of  six  weeks 
after  the  disease  itself  had  ceased  to  exist,  but  after  this  time  no 
casts  were  found.  Loeb"  reports  propeptonuria  present  in  9  out  of 
12  cases  examined  at  the  height  of  the  malady. 

1  Richter.     Monographie,  Berlin,  1828. 

-  Blumer  and  MacFarland.     Loc.  cit. 

3  Antonucoi.     Gaz.  degli  Ospedali/No.  69,  1908. 

^  Majima.     Jahrbuch  f.  Kinderheilk.,  64,  No.  5,  p.  651. 

'  Perriu.     Ann.  de  m^d.  et  cliir.  inf.,  Paris,  1903,  ^•ii,  109  to  114. 

'  Wunder.     Munch,  med.  Wochenschrift,  Jlay  18,  1897. 

'  Thomas.     Von  Ziemssen's  Cyclopaedia. 

8  Eichhorst.     Deutsch.  Archiv  f.  klinische  Med.,  Band  Ixx,  Heft  5. 

9  Helleneu.     Jahrbuch  f.  Kinderh.,  1908,  Ixvii,  294. 

1"  Gregory  and  Rilliet.      Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  512. 
"  Loeb.     Trans.  Med.-Chir.  Soc,  Ixxii,  57.     (Quoted  by  Dawson  Williams.) 


362  MEASLES 

Thomas'  ([iu)tt\s  1.")  autlioi's  as  having'  iiu't  with  nephritis  chirino- 
measles  and  is  of  the  opinion  that  it"  the  urine  was  examined  as 
carefully  and  over  as  lon^'  a  period  as  it  is  in  scarlet  fever,  we 
would  liiul  nephritis  a  miuh  more  common  complication  of  measles 
than  is  generally  believed.  Fatal  cases  of  measles  complicated  by 
urjemia  have  been  reported  by  several  writers,  among  them  Miiller,^ 
Demme,^  Browning/  and  Zichy-AVoinarski."  \Vhen  the  kidneys  are 
seriously  in\ olved  there  may  be  general  anasarca  present,  as  in  the 
cases  reportetl  by  Abeille,"  Denizet,^  and  Comby^  (2  cases).  One 
of  us  (Beardsley)  saw  a  case  of  this  kind  which  appeared  during 
convalescence  in  an  Italian  girl,  aged  sixteen  years.  There  was 
marked  oedema  of  the  extremities  and  the  abdomen  was  distinctly 
distended  with  fluid,  but  the  patient  recovered,  although  there 
were  still  many  casts  in  the  urine  and  a  trace  of  albumin  present 
when  tlie  girl  last  attended  tiie  dispensary  at  the  Starr  Centre 
Dispensary. 

Hsematuria  is  an  unusual  hnding  in  the  ordinary  variety  of 
measles,  but  in  the  malignant  forms  of  the  disease,  hsematuria  is 
a  frequent  complication.  Bambace"  reports  an  epidemic  in  which 
hsematuria  was  a  frequent  finding,  and  in  all  the  descriptions  of 
"black  measles"  hsematuria  is  almost  constantly  referred  to. 

Urethritis  during  measles  must  be  an  infrequent  symptom  in 
male  children,  as  we  have  been  unable  to  find  any  reference  to  it  in 
the  literature,  although  one  of  us  saw  three  cases  during  the  past 
winter.  All  the  cases  were  in  young  boys,  their  ages  being  respec- 
tively five,  six,  and  nine  years.  In  one  boy  there  was  evidence  that 
there  had  been  introduced  into  the  urethra  some  foreign  body,  but 
in  the  other  cases  the  boys  denied  any  knowledge  of  the  discharge 
until  it  was  discovered  by  routine  examination  of  the  body.  The 
discharge  was  examined  microscopically,  but  although  there  was 
much  pus  present,  no   bacteria  were  found.     Injections  of   salt 

'  Tliomas.      In  Von  Ziemssen's  Cyclopsedia. 

2  Miiller.     Quoted  by  Welch  and  Schamberg,  Acute  Contagious  Diseases,  p.  512. 

'  Demme.     Ibid. 

*  Browning.     Ibid. 

'  Zichy-Woinarski.     Australian  Medical  Gazette,  October  1.5,  1893. 

6  Abeille.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  512. 

'  Denizet.     Ibid. 

8  Comby.     Ibid. 

'  Bambace.     Gazette  degli  Osped.,  Milan,  April  5,  29,  No.  41. 


77//-;  iii<:art  and  jn.oo/jv/'Jssf'JLS  :>,(;?, 

solution  WiiS  the  only  (rcjilinciil,  used,  ;ui(|  (lie  coiMlil  inn  di  ;i|)[)<;i  rcl 
in  tlircc  diiys. 

Vulvitis  is  ii  rclalivcly  roniinon  coinplicnlion  of  severe  iittacks  of 
measles,  and  is  by  no  ineiuis  nncoiimioiily  seen  in  oi(lin;iry  attacks 
of  measles.  (>)ml)y'  observed  vulvitis  in  27)  eases  among  715  eases 
of  measles  treated  in  isolation  pavilions.  Tt  must  be  remembered, 
however,  that  vulvitis  is  by  no  means  an  nncommon  eoniplieation 
in  ehildren's  homes  and  lios|)ilaIs  even  when  no  aente  cruplive 
ilisease  is  pi-esent. 

Vulvitis  din-ing  measles  begins  early,  as  a  rule,  and  has  a 
tendency  to  persist.  The  parts  are  red,  swollen,  covered  with  a 
mucopurulent  discharge,  and  are  extremely  tender.  Micturition 
is  accomplished  only  with  difficulty,  and  causes  much  pain.  In  a 
few  cases  vulvar  ulceration  occurs,  and  occasionally  gangrene. 

Gangrene  of  the  genital  regions  in  both  sexes  has  been  mentioned 
under  noma  and  under  gangrene  of  the  skin  (loc.  cit.,  p.  355). 

The  Heart  and  Bloodvessels. — The  heart  and  bloodvessels 
are  not,  as  a  rule,  subject  to  complicating  lesions  during  measles, 
although  it  is  by  no  means  rare  for  the  heart  muscle  to  be  weakened 
in  the  course  of  a  very  severe  attack,  and  death  may  occur  from 
what  is  commonly  termed  "heart  failure,"  wh'ch  is  probably  an 
infectious  myocarditis. 

Welch  and  Schamberg^  report  the  case  of  a  young  child  who 
fell  back  upon  the  pillow  dead  after  the  effort  of  sitting  up  in  bed 
durine;  convalescence,  and  two  other  children  in  the  same  familv 
died  during  the  same  epidemic  of  profound  toxaemia.  Williams^ 
states  that  fatty  degeneration  has  been  found  post  mortem  in  cases 
of  measles  in  which  during  life  the  first  cardiac  sound  had  been  in- 
distinct, and  in  some  cases  there  have  been  noted  systolic  murmurs. 
Most  writers,  however,  agree  with  MacKenzie,*  I>ee,'  Sturges,** 
and  Corlett,^  that  the  few  cases  on  record  do  not  show  any  evidence 
that  measles,  per  se,  induces  disease  of  the  cardiac  muscle. 

1  Comby.     Traite  des  Maladies  de  I'Enfance,  1902,  i,  190. 

2  Welch  and  Scliamberg.     Acute  Contagious  Diseases,  p.  511. 
'  Williams.     Trans.  Med-Chir.  Soc,  Ixxvii,  57. 

*  MaeKenzie.     British  Medical  Journal,  February  26,  1SS7,  p.  425  et  seq. 
s  Lee.     Trans.  Medico-Chir.  Soc,  1S91,  Ixxiv.  229  et  seq. 
«  Sturges.     Trans.  Medico-Chir.  Soc,  1891,  Ixxiv,  229  et  seq. 
7  Corlett.     The  Acute  Exanthemata,  p.  306. 


364  MEASLES 

Endocarditis  diiring  measles  is  even  more  rare  than  is  myocarditis. 
Cases  have  been  reported  bv  Hutchison,*  Cheadle,"  Martineau,^ 
West/  Kobler,^  Comby;"  and  Sansom/  but  the  majority  of  these 
cases  were  based  upon  the  presence  of  cardiac  miumurs  during 
life  rather  thaii  upon  the  finding  of  endocarditis  at  autopsy. 

Pericarditis  chuing  measles  is  also  a  rare  complication,  and  when 
seen  usually  complicates  a  maligjiant  case  of  the  disease.  Auten- 
rieth,  Berndt,  Majer,  Espinouse,  Braun,  Siegel,  Mettenheimer,  and 
He\-felder  are  all  quoted  by  Thomas^  as  having  met  with  cases  of 
pericarditis  during  the  course  of  measles.  It  is  stated  by  several 
of  these  writers  that  pericarditis  is  particular  likely  to  occur  in 
cases  of  measles  that  are  complicated  by  pulmonary  affections. 

Phlebitis  as  a  complication  of  measles  is  extremely  rare.  Zam- 
boni^  and  Mackey"'  have  each  reported  a  case.  In  each  patient 
the  condition  was  bilateral  and  both  patients  died. 

The  Ears. — ^The  ears  during  an  attack  of  measles  are  more 
often  affected  than  is  usually  thought  by  those  who  do  not  see  a 
large  number  of  cases.  Bezold^^  examined  the  ears  of  sixteen 
subjects  who  had  died  as  the  result  of  measles,  and  found  in  each 
case  inflammatory  changes,  and  in  addition  the  tympanic  cavity 
contained  either  mucopus  or  pus.  Tobietz^^  examined  the  ears  of 
twenty-two  subjects  and  confirmed  the  findings  of  Bezold.  Both 
of  the  above  writers  are  in  accord  as  to  the  presence  of  early  aural 
catarrh.  The  catarrhal  inflammation  is  not  looked  upon  as  a 
secondary  infection,  but  rather  as  the  result  of  the  localization  of 
the  exanthem. 

Catarrhal  otitis  media  may  develop  very  early  in  the  disease. 
In  one  case  studied  by  Tobietz  the  child  died  twenty-four  hours 
after  the  appearance  of  the  eruption,  but  there  was  already  present 
otitis  media. 

'  Hutchison.     Trans.  Med.-Chir.  Soc,  1891,  vol.  xxiv. 

*  Cheadle.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  511. 

3  Martineau.      Ibid.  *  West.     Ibid.  '  Kobler.     Ibid. 

8  Coniby.     Quoted  by  Williams  in  Trans.  Med.-Chir.  Soc,  Ixxvii,  57. 
'  Sansom.     Quoted  by  Williams,  loc.  cit. 

*  Thomas.     In  Von  Ziemssen's  Encyclopaedia. 

'  Zamboni.     Bull,  de  Sc.  Mdd.  de  Bologne,  1808,  vii,  S.  8,  p.  548. 
">  Mackey.     British  Medical  Journal,  December  19,  189G. 
"  Bezold.     Munch,  med.  Woch.,  1896,  Nos.  10  and  11. 
1' Tobietz.     British  Medical  Journal,  1894,  viii,  1163. 


77//';  i<:yI':s  .'ifio 

Severe  purulent  otitis  media  is  more  often  s(!en  in  eertain  epi- 
demies  than  in  otliers.  Downie'  found  that  elu'ldren  that  suffe-red 
from  adenoid  growths  were  particularly  likely  to  develoj)  otitis  media 
during  an  attack  of  measles.  It  has  heen  noted  by  many  f>hsen'ers, 
that  the  early  otitis  is,  as  a  rule,  mild,  but  the  secondary  infections 
from  the  nasopharynx  is  much  more  prone  to  result  in  suppuration. 

In  severe  cases  of  middle  ear  disease  neerfxsis  of  the  ossicles  or  of 
the  surrounding  bony  walls  may  take;  place.  T'urknei^  reports 
such  cases  and  states  that  they  are  frequent. 

Downie,  in  501  cases  of  tympanic  involvement,  found  tli;it  lol, 
or  26.1  per  cent.,  were  due  to  measles. 

Deaf  mutism  is  not  frequently  due  to  an  attack  of  measles  in 
which  there  has  been  serious  labyrinthian  necrosis. 

Kerr,  Love,  and  Addison^  have  collected  statistics  from  institu- 
tions in  Great  Britain  which  show  that  of  1140  deaf  mutes,  138, 
or  9.8  per  cent.,  attributed  their  misfortune  to  an  attack  of  measles. 

In  American  institutions,  of  1673  acquired  cases  of  deaf  mutism, 
52,  or  3.1  per  cent.,  were  due  to  measles.  Among  1989  acquired 
cases  on  the  continent  of  Europe,  84  cases,  or  4.2  per  cent.,  were 
ascribed  to  this  disease.  Of  487  children  admitted  to  the  Ohio 
Institute  for  the  education  of  the  Deaf  and  Dumb,  14  gave  a  history 
of  a  previous  attack  of  measles  as  the  cause  of  their  deafness. 

Mastoid  suppuration  may  occur  as  a  sequel,  or  even  as  a  com- 
plication, of  measles,  but  this  occurrence  is  rare.  In  general,  the 
pathological  changes  that  occur  in  the  ear  as  the  result  of  measles 
are  less  serious  than  are  those  which  appear  during  or  subsequent 
to  an  attack  of  scarlet  fever. 

Intracranial  abscesses,  meningitis,  and  thrombosis  of  the  lateral 
sinus  are  all  accidents  which  have  occurred  during  convalescence, 
but  the  conditions  are  very  rare  as  sequels  to  an  attack  of  measles. 

The  Eyes. — ^The  eyes  are  always  affected  w'ith  some  degree  of 
conjunctivitis,  but,  as  a  rule,  this  condition  is  not  dangerous,  although 
corneal  ulcers  are  by  no  means  rare  in  the  wards  where  children  are 

1  Downie.     British  Medical  Journal,  1894,  ii,  1163. 

2  Burkner.     Behandlung  der  bei  Infectionskrankheiten  Vorkommenden  Ohraffectionen, 
loc.  cit.,  p.  581. 

3  Kerr,  Love,  and  Addison.     A  Clinical  and  Pathological  Study  of  Deaf  Mutism,  Glas- 
gow. 1S96. 


366  MEASLES 

suffering  from  measles.  In  addidoii  to  corneal  nlceratlon,  we  see 
cases  of  blepharitis,  granular  lids,  and  occasionally  cases  of  specific 
conjunctivitis. 

By  far  the  most  serious  complication  that  attacks  the  eye  is  the 
corneal  ulceration,  which  unfortunately  at  times  results  in  total 
blindness  as  the  result  of  the  perforation  of  the  cornea.  Rollet^ 
has  reported  such  a  case. 

Di])htheritic  conjunctivitis  is  occasionally  seen  during  measles^ 
and  the  condition  is  a  dangerous  one, for  it  usually  occurs  inana?niic, 
scrofulous  children  whose  resistance  is  already  at  a  low  ebb.  The 
corneal  ulcers  that  complicate  the  condition  fail  to  respond  to  any 
treatment,  and  not  infrequently  the  cornea  perforates  and  the  eye  is 
lost.  Lougier  has  collected  22  cases  of  diphtheritic  conjunctivitis 
during  measles,  in  10  cases  of  which  death  resulted,  and  in  5  there 
was  the  loss  of  one  or  both  eyes. 

Empyema  of  the  frontal  sinus  during  an  attack  of  measles  has 
been  repoi'ted  by  Belin,^  and  is  probably  more  frequent  than  the 
dearth  of  literature  upon  the  subject  would  indicate. 

The  Nervous  System. — The  nervous  system  during  an 
attack  of  measles  may  suffer  a  variety  of  disturbances  from  the 
effect  of  the  specific  toxin  of  the  disease,  but  when  we  consider  how 
frequent  a  disease  is  measles,  we  realize  that  seiious  complications 
of  the  nervous  system  are  rare. 

Convulsions  sometimes  usher  in  an  attack  of  measles,  especially 
in  young  children.  INIcTlrath'*  found  that  of  250  children  with 
convulsions,  in  7  an  attack  of  measles  was  the  etiological  factor. 
The  appearance  of  convulsions  during  the  disease,  as  a  rule,  indi- 
cates the  onset  of  grave  nervous  complications. 

Cerebral  paralysis  as  the  result  of  an  attack  of  measles  is  unusual,, 
but  Allyn^  was  able  to  collect  35  instances  in  which  this  complica- 
tion occurred.  In  Wallenberg's'*  series  of  160  cases  of  cerebral 
paralysis  8  cases  occurred  during  an  attack  of  measles.     Gowers^ 


1  Rollet.     Ann.  Med.-Chir.,  Tours,  1903,  iii,  90. 

^  Lougier.     Revue  Mensuelle  des  Maladies  des  Enfants,  June,  189G,  p.  294. 

3  Belin.     Soc.  M(5d.  des  Hopitaux,  May  30,  1902. 

*  Mcllrath.     Medical  Chronicle,  November  and  December,  1906,  and  January,  1907. 

'  Allyn.     Medical  News,  November  28,  1891. 

8  Wallenberg.     Jahrbueh  f.  Kinderheilkunde,  1886,  xxiv,  384  to  439. 

'  Gowers.     Manual  of  Diseases  of  the  Nervous  System,  1888,  ii,  423. 


77/ A'  NI':iiV()(IS  SVST/m  367 

has  socn  7  instances,  Osier'  I,  Alieicidinl.ic'  !,  ;iii<l  l;illi«t  ;iiifl 
Bardie/  I. 

TluM)nset  ol"  lliis  eoinplienlion  is  ;il»iii|)(  iiiid  eoininoiily  jis.^tjfi- 
ated  with  convnlsions,  bnt  in  other  eases  tiH;re  is  present  soinfiohmee 
or  even  coma  from  the  he^inninn;.  p\j||(nvin^  tlic  convulsions  or 
coma  the  paralysis  is  first  noted.  The  paralysis,  accf)r(ling  to 
Allyn,  usually  appears  during  convalescence,  and  most  frecjueridy 
from  the  latter  part  of  the  first  to  the  end  of  the  third  week  nfter 
the  onset  of  the  jnimary  malady.  Of  21  reported  cases,  11  devel- 
oped palsy  between  the  fifth  and  sixteenth  days,  ;inr|  fi\-e  otinr 
eases  probably  belong  to  this  period,  aUhough  the  data  is  lucoin- 
plete.  In  the  remaining  cases  3  developed  convulsions  on  the 
second  day  of  the  eruption,  1  case  a  month  after  the  onset  of  the 
attack  of  measles,  and  1  occurred  between  five  and  six  weeks  after 
the  onset  of  the  measles.  The  prognosis  as  to  life  is  good.  In  only 
4  of  the  series  of  Allyn  did  death  take  place.  In  some  of  the  cases 
the  lesions  were  more  or  less  permanent,  aphasia  and  muscular 
atrophy  persisting  for  months  or  years  after  the  attack. 

Sjnnal  paralysis  is  rare  in  measles,  but  when  seen  is  most  likely 
to  be  an  acute  poliomyelitis  or  a  disseminated  myelitis. 

Bergeron  and  Liegeard,^  Bruckener,''  Ellison,'^  and  others  have 
reported  instances  of  acute  ascending  paralysis  during  measles. 

Dawson  Williams"  has  reported  a  case  of  disseminated  sclerosis 
in  a  child,  aged  three  and  a  half  years,  on  the  fourth  day  of  an 
attack  of  measles,  and  both  Bruce^  and  Barlow*  saw  cases  of  diffuse 
myelitis  during  the  course  of  this  disease.  Landouzy^  was  of  the 
opinion  that  paraplegia  was  frequent  as  a  complication  of  measles, 
but  few  cases  are  noted  in  the  literature.  Ortholon'"  reports, 
however,  a  case  of  paraplegia  in  a  three-year-old  girl. 


1  Osier.     Cerebral  Palsies  of  Children. 

-  Abercrombie.     British  Medical  Journal,  1887,  i,  1323. 

'  Bergeron  and  Liegeard.     Quoted  by  Gowers,  Diseases  of  the  Nervous  System,  p.  898. 

*  Bruckener.     Jahrbuch  f.  Kinderheilkunde,  1902,  Band  Ivi. 

^  Ellison.     Lancet,  October  17,  1896.     Also  Mackey.     British  Medical  Journal,  Decem- 
ber 19,  1896. 

^  Dawson  Williams.     Trans.  Med.-Chir.  Society,  Ixxvii,  57. 

'  Bruce.     Quoted  by  Welch  and  Schamberg,  Acute  Contagious  Diseases,  p.  305. 

*  Barlow.     Trans.  Med.-Chir.  Society,  Ixx,  77. 

^  Landouzy.     Quoted  by  Gowers  in  Manual  of  Nervous  Diseases. 
10  Ortholon.     These  de  Bordeaux,  November  23,  1894. 


368  MEASLES 

False  disseminated  sclerosis  occasionally  occurs  during  an 
attack  of  measles,  as  in  other  infectious  diseases.  It  may  occur 
eaily  in  the  attack  or  during  convalescence.  Instead  of  the  condi- 
tion being  progressive,  there  is  a  distinct  tendency  to  improve. 
Barthez  and  Sanne*  have  collected  a  series  of  S  cases  of  multiple 
neuritis  characterized  by  paresis  of  the  soft  palate,  pharynx, 
tongue,  and  muscles  of  the  neck.  In  4  cases  these  svmptoms 
appeared  early  and  the  other  four  at  the  end  of  three  weeks. 
Recovery  took  place  in  all  of  the  cases  in  from  three  to  twenty 
days. 

Muscidar  atrophy  as  a  result  of  paralysis  during  measles  some- 
times occurs.  In  nearly  all  cases  in  which  the  paralysis  continues 
for  some  time  there  is  atrophy  of  the  muscles  of  the  limb  affected, 
but  Coote^  has  reported  a  case  so  severe  that  it  gave  rise  to  talipes 
equinus.  Ormerod^  had  under  his  care  a  father  and  two  children, 
all  affected  with  muscular  atrophy  following  measles. 

Aphasia  as  a  complication  of  measles  is  by  no  means  unknown. 
It  sometimes  appears  without  accompanying  paralysis,  but  this 
is  rare.  Smith,^  Gilman,^  Lucas,^  and  Majer^  all  report  instances 
in  which  aphasia  occurred  during  measles. 

Polioencephalitis  as  a  complication  of  measles  has  been  seldom 
met  with,  but  Smith*  and  Guthrie"  have  both  met  with  this  condi- 
tion. 

Ataxia  following  measles  has  been  infrequently  seen.  Fair- 
banks^" saw  a  case  of  this  kind  in  a  child  four  and  a  half  years  of 
age  that  recovered. 

Meningitis  complicating  measles  is  not  often  seen  except  in  those 
cases  in  which  the  ear  complications  bring  it  about.     Harvey"  has 


1  Barthez  and  Sanne.     Traitd  cliniq.  et  pratiq.  des  mal.  des  enfants,  1891,  tome  3,  p.  38. 

2  Coote.     Quoted  by  Williams  in  Trans.  Medico-Chir.  Soc,  Ixxvii,  57. 

*  Ormerod.     Brain,  1885,  vii,  335. 

*  Smith.     Reports  of  Society  for  tlie  Study  of  Disease  in  Children,  April  15,  1904. 
'  Gilman.     Boston  Medical  and  Surgical  Journal,  August  13,  1903. 

*  Lucas.     London  Medical  Journal,  1790. 

''  Majer.     Lancet,  February  6,  1897.      Quoted   by  Hall,  New  York  Medical  Journal, 
1887,  ii,  347. 

8  Smith.     Loc.  cit.,  October  21,  1904. 

^  Guthrie.     Report  of  Society  for  the  Study  of  Children's  Diseases,  1905,  i,  13. 
1"  Fairbanks.     Arch,  of  Pediat.,  1907,  p.  770. 
J'  Harvey.     Journal  of  the  American  Medical  Association,  1897,  xxix,  1149 


77//';  N/'JU,\OUS  SYS'I'HM  ?,()() 

reported  rneiiiii^'ifis  during  iiieuslcs,  urid  'Jliftrriiis'  f|Uo(.e.s  Spiess, 
Voit,  Meyer-IIoll'meisler-,  Kclliior,  (Joustanl,  Loseliiier,  Tliore, 
Burfalini,  King,  iind  Alcllcnliciiiier  as  having  met  witli  this  compli- 
cation. 

tSpitial  virmm/ifis  is  another  rare  eomph'eation  of  measles. 
Frank,  Rilliet,  and  Starck^  have  observed  cases. 

Neuritis  (hu-inn-  oi-  follctwinn-  measles  is  a  rare  foniplic-idon,  lint 
has  been  noted  by  several  observers.  Ilevilliod  and  Lfjiig'  have 
reported  a  case,  in  which  many  nerves  were  involved,  that  ajjpeared 
on  the  sixth  day  of  the  illness  and  disappc^ared  after  two  jnonths. 
Allaria"*  and  Edens"'  have  reported  similar  cases. 

Tetany  is  an  extremely  rare  complication,  and  is  usually  met  with 
in  very  young  children  who  have  previously  shown  a  tendency 
toward  convulsions. 

Mental  disorders  during  and  following  measles  are  rare,  but  in 
certain  predisposed  individuals  an  attack  of  measles  may  be  the 
factor  which  brings  about  insanity.  Finkelstein"  saw  two  cases  of 
mania  after  measles,  and  Bond^  reported  a  case,  aged  twenty-five 
years,  that  developed  mania  on  the  eighth  day  of  the  disease. 
Smith  and  Dabney**  reported  three  cases  of  insanity  during  an 
epidemic  of  108  cases  of  measles  in  children,  but  all  three  recov- 
ered. Beach®  analyzed  the  histories  of  2000  cases  of  idiocy,  and 
found  that  37  of  these  cases  could  be  traced  to  attacks  of  infectious 
diseases,  and  of  this  number,  11  were  due  to  measles. 

Casson^"  reports  a  case  of  complete  dementia  in  which  recoveiy 
occurred  suddenly.  Rarely  a  patient  recovering  from  measles 
remains  in  a  dull,  stupid  state. 

Chorea  is  an  occasional  sequel  of  measles.  In  the  analysis  of 
439  cases  of  chorea  made  by  MacKenzie"  for  the  Collective  Investi- 

1  Thomas.     In  Von  Ziemssen's  Cyclopcedia. 

2  Starck.     Deutsche  Archiv  f.  khn.  Med.,  1896,  vol.  Ivii. 

'  Revilliod  and  Long.     Arch,  de  M^decine  des  Enfants,  March,  1906. 
*  Allaria.     Gaz.  de  Osp.,  Milan,  1905,  xxvi,  164. 

6  Edens.     Berlin,  klin.  Wochensch.,  1904,  xU,  849. 
"6  Finkelstein.     Vratch,  1898,  No.  20. 

7  Bond.     Maryland  Medical  Journal,  January  29,  1898. 

s  Smith  and  Dabney.  Quoted  by  Welch  and  Schamberg,  Acute  Contagious  Diseases, 
p.  506. 

9  Beach.     British  Medical  Journal,  1895,  ii,  707. 
10  Casson.     Lancet,  1886,  ii,  1020. 

1'  MacKenzie.     British  Medical  Journal,  February  26,  1887,  p.  425. 
24 


370  MEASLES 

nation  Committee  of  the  British  Medical  Association,  measles  was 
found  to  he  the  sole  antecedent  illness  in  49  cases  (9  per  cent.). 

Bones  and  Joints. — Arthritis  compllcatuig  measles  is  an  ex- 
tremely rare  condition,  but  has  been  observed.  Craik*  has  reported 
a  case  of  this  kind  in  which  the  joint  was  aspirated  and  a  quantity 
of  pus  withdrawn. 

Osteitis,  osteomycliiis,  and  necrosis  of  hones  during  measles, 
although  rare,  is  more  common  than  would  be  indicated  by  the  very 
sparse  literature  upon  the  subject.  The  reason  for  such  cases  not 
being  reported  is  probably  the  length  of  time  necessary  for  the 
development  of  the  bony  lesion  after  convalescence.  Sadena^  has 
reported  necrosis  of  the  maxilla,  and  in  the  "Sei-i-kirai"^  a  case  is 
recorded  in  which  necrosis  occurred  in  both  maxilla  during  the 
coui-se  of  measles.  One  of  us  (Beardslej^)  saw  two  cases  of  necrosis 
of  the  mandible  in  young  children  occurring  several  weeks  after 
measles  without  any  other  factor  which  would  tend  to  produce 
necrosis  of  the  bone.  Riera^  has  reported  a  case  in  which  both  the 
costal  cartilage  and  bone  were  involved. 

Pregnancy  when  complicated  by  measles  is  often  ended  by 
premature  delivery,  hemorrhage,  and  septic  infection.  Atkinson^ 
has  written  upon  this  subject,  and  finds  that  measles  is  an  important 
cause  of  death  during  the  puerperium. 

Relapse. — Relapse  following  the  initial  attack  of  measles  is 
rare,  but  has  been  reported  by  several  writers.  Trujansky"  has  seen 
14  cases  in  which  relapse  took  place.  Kassowitz,^  Leach,^  Weill 
and  Danvergue,^  Chauffard  and  Lemoine,^"  Eonnet,"  and  Comby^" 
have  all  observed  several  cases  of  relapse  in  measles.  It  is  to  be 
remembered,  however,   that    postrubeolic    eruptions,   even   when 


*  Craik.     Lancet,  January  24,  1903,  p.  237. 

=  Sadena.     Med.  de  los  Ninos  Barcel.,  1904,  v,  81  to  84. 
3  Sei-i-kwai.     Tokyo,  27,  Nos.  2  and  4. 

*  Riera.     Med.  de  los  Nines  Barcel.,  1908,  ix,  272. 

5  Atkinson.      British  Medical  Journal,  1908,  ii,  407. 
^  Trujansky.     Dorpater  Med.  Zeitsch.,  1873,  iii. 
'  Kassowitz.     Jahrbuch  f.  Pediatrik,  Band  i,  1874. 

*  Leach.     Lancet,  December  23,   190.5. 

9  Weill  and  DanverRue.     Lyon  M(^d.,  1907.  No.  3,  p.  98. 
'"  Chauffard  and  Lemoine.     Gaz.  med.  de  Paris,  1896,  tome  3,  No.  1. 

11  Eonnet.     Gaz.  hebdom.  de  'SIM.  et  de  Chir.,  October  29,  1896. 

12  Comby.     Maladies  des  Enfants,  October  1,  1904. 


morbiinroriii  in  cliiiiiiclci-,  do  iiol  alwiiys  iiKliciifc  ;i  relapse.  Hoger* 
has  seen  iiiaiiy  cases  of  uwidciitiil  crytlierMutoii.s  rash. 

Second  Attacks.  -Second  attacks  of  measles  are  verv  much 
more  rare  than  ar-c  rchipses,  which  are  sometimes  called  second 
attacks.  As  a,  imiIc,  one  attack  of  measles  ])rotect.s  an  individual 
for  lifetime  from  another  attack,  hut  there  are  undouhtcd  cases 
in  which  two  attacks  of  ty})ical  measles  have  occurred  in  the 
same  individual.  Senator/  Emhden,'  Sirens;,'  Jlenoch,'  Ilennig,* 
and  Dupaquler^  have  all  reported  undoubted  second  attacks  of 
this  disease.  Maizelis^  was  able  to  collect  100  cases  of  moj-e  than 
one  attack  of  measles  in  an  individual.  There  were  103  second 
attacks  and  three  cases  in  which  three  attacks  had  occurred. 
Adriance"  collected  10  cases  that  had  second  attacks  from  cases 
under  his  care. 

Third  Attacks. — Third  attacks  are,  of  course,  still  more  unusual, 
but  have  been  reported  by  Streng^°  and  Maizelis." 

Sequels. — Although  it  is  true  that  the  sequels  of  an  attack  of 
measles  may  be  any  of  the  numerous  complications  that  have 
been  mentioned,  it  is  also  true  that  three  organs  are  the  most  fre- 
quently affected  These  organs  are  the  ears  the  lungs,  and  the 
glandular  system.     (See  Complications.) 

Otitis  media  is  the  most  frequent  and  important  sequel  of  measles. 
In  many  cases  this  condition  persists  for  years  and  sometimes  for 
life,  and  is  not  only  a  danger  to  life,  but  causes  great  inconvenience 
by  the  deafness  resulting  from  the  destruction  of  the  structures  of 
the  inner  ear. 

The  pulmonary  affections  complicating  measles,  particularly  the 
bronchopneumonias,  often  become  tuberculous,  but  it  is  an  open 
question  as  to  whether  the  tuberculous  infection  is  not  the  primary 


1  Roger.     Les  Maladies  Infectieuses,  p.  875. 

-  Senator.     Jahrbuch  f.  Kinderheilkunde,  Band  xxxiv,  p.  91. 

2  Embden.     Quoted  in  Penzoldt  und  Stintzings  Handb.  der  Speciellen  Ther.,  1894. 
■*  Strang.     Jahr.  f.  Kinderh.,  Band  xxxvi. 

^  Henoch.     Ibid.,  Band  xxii. 

6  Hennig.     Ibid.,  New  Series,  vol.  viii,  p.  417. 

^  Dupaquier.     New  Orleans  Medical  and  Surgical  Journal,  vol.  liii,  p.  1, 

s  Maizelis.     Yirchow's  Archiv,  No.  137,  p.  468. 

'  Adriance.     Archiv.  de  Pediat.,  February,  1900. 
10  Streng.     Loc.  cit. 
1'  Maizelis.     Loc.  cit. 


372  MEASLES 

one.  Certainly,  it  is  trne  that  tuberculosis  of  the  lungs  is  a  fre- 
quent secjuel  of  measles.  This  is  due  no  doubt  to  a  former  latent 
tuhereulous  infeetion  becoming  active  during  the  debilitated  con- 
dition of  the  patient,  whose  resistance  to  infection  is  much  lowered 
bv  the  attack  of  measles. 

The  glandular  system  often  suffers  both  tluring  and  after  an 
attack  of  measles.  The  glands  most  often  affected  are  the  sub- 
maxillary, and  suj)})urati<)n  is  frequent. 

The  junior  author  has  seen  sixteen  cases  of  suppuration  of  the 
submaxillary  glands  following  measles  in  children  at  the  Starr 
Centre  Dispensary  during  the  past  nine  months.  The  cervical 
glands  are  prone  to  become  tuberculous  following  an  attack  of 
measles. 


CHA  I'TKIl    I  V. 

VAIllCKLLA  (CIIICKKNI'OX). 

Varicef.LA  is,  In  tlu'  miijoriiy  of  instances,  a  mild  disease  anrj 
free  from  danger  to  life,  jdtliou^h  in  seven;  attacks  the  rlisciise 
may  closely  resemble  variola,  and  hy  coiiij)lif;ilioiis,  or  even  \>y 
severe  toxaemia,  may  bring  about  the  patient's  death. 

The  usual  attack  of  varicella  is  easily  recognized,  and  the  initial 
symptoms  are  slight,  in  fact,  are  often  unnoticed,  particularly 
in  young  children.  A  child  is  sometimes  fretful  for  a  few  hours 
before  the  appearance  of  the  rash,  and  there  may  be  headache  or 
vague  body  pains,  with  a  complaint  of  chilliness  or  even  an  actual 
chill,  while  vomiting  is  occasionally  seen  about  the  time  the  rash 
appears.  In  rare  cases  the  initial  symptoms  are  severe  and  are 
accompanied  by  drowsiness,  less  often  by  delirium  and  convulsions, 
and  rarely  by  coma. 

Thomas^  has  reported  a  case  with  an  initial  temperature  of  106°, 
and  MacCombie^  has  on  several  occasions  noted  delirium  as  an 
initial  symptom,  while  Henoch,^  Jennings,*  Tham,''  and  other  clini- 
cians have  reported  convulsions  which  complicated  the  disease  at 
its  onset. 

The  severity  of  the  symptoms  and  the  duration  of  the  acute  stage 
of  the  illness  depend  upon  several  things:  First,  upon  the  health  of 
the  patient  immediately  preceding  the  attack  and  the  amount 
of  resistance  the  body  tissues  oflfer  to  the  toxins  of  the  disease, 
and  second,  upon  the  abundance  of  the  eruption  and  the  number 
of  crops  of  vesicles  that  appear,  the  degree  of  suppuration  in  the 
vesicles,  and  upon  the  number  of  lesions  in  which  inflammation, 
ulceration,  and  gangrene  take  place  following  the  rupture  of  the 
vesicles. 

1  Thomas.     In  Von  Ziemssen's  Cyclopaedia  of  Medicine  (Varicella). 

2  MacCombie.     In  System  of  Medicine  by  Allbutt  and  Rolleston  (Varicella),  p.  477. 
'  Henoch.     Vorlesungen  ilber  Kinderkrankheiten,  Wien,  1S90,  p.  211. 

*  Jennings.     Keating's  Cyclopaedia  of  Medicine  (Varicella),  i,  762. 

*  Tham.     Jahrbuch  f.  Kinderheilkunde,  Neue  Folge,  Band  xxv,  5,  155,  156. 


374  VARICELLA 

Prodromal  Rashes.— These  are  by  no  means  uncommon,  and 
occur  froui  twx)  tt)  twenty-four  hours  before  the  varicellous  eruption. 
The  scnrhitiniform  initial  rash  is  the  most  common,  ahhough 
urticarial  as  well  as  morbilliform  rashes  have  been  infrequently 
reporteil.  MacCombie'  reported  the  case  of  a  o'irl,  aged  seven  years, 
whose  skin  was  covered  by  a  very  marked  erythema,  accompanied 
by  many  urticarial  wheals,  twenty-four  hours  before  the  appear- 
ance of  the  vesicular  eruption.  Rolleston^  has  recently  called 
attention  to  the  accidental  rashes  which  occur  preceding  and 
during  the  attacks  of  varicella.  He  thinks  that  the  initial  erytiiemas 
are  sometimes  mistaken  for  the  rasii  of  scarlet  fever.  Cerf^  was 
able  to  collect  45  cases  in  which  there  had  been  seen  prodromal 
rashes. 

Skin  Lesions. — Gangrene  of  the  Skin. — This  occasionally 
follows  the  rupturing  of  the  vesicles,  and  is  caused  by  secondary 
pyogenic  infections.  It  is  most  likely  to  attack  very  young  children 
who  live  in  unhygienic  surroundings,  particularly  those  whose 
nutrition  and  general  health  are  poor.  In  mild  cases  of  this  com- 
plication but  few  of  the  many  varicellous  lesions  undergo  necrosis 
and  gangrene;  in  some  cases,  however,  large  numbers  of  the  vesicles 
are  involved. 

Hutchison^  has  referred  to  these  cases  as  examples  of  "varicella 
gangra?nosa,"  but  it  is  to  be  remembered  that  the  gangrenous  condi- 
tion is  not  to  be  regarded  as  a  variety  of  varicella,  or  even  as  a  com- 
plication peculiar  to  this  disease,  as  it  may  occur  in  vaccinia,  variola, 
scarlatina,  erysipelas,  typhoid  fever,  and  other  diseases;  but  it  is 
true  that  this  complication  most  commonly  complicates  varicella. 
Crocker^  has  written  an  excellent  description  of  this  affection,  w^hile 
many  men  in  various  countries  have  repoi-ted  experiences  with  it. 

Impetigo  Varicellosa. — It  is  very  common  in  varicella  for 
the  infection  of  the  drying  lesions  to  take  place,  and  in  many  cases 
blebs  and  pustules  form  which  may  become  of  considerable  size. 
These  have  been  appropriately  designated  by  Welch  and  Scham- 

•  MacCombie.     Loc.  cit.,  p.  477. 

-  Rolleston.     British  Journal  of  Children's  Diseases,  January,  1906. 
'  Cerf.     Quoted  by  Crocker,  loc.  cit. 

*  Hutchinson.     Clinical  Lectures,  i,  15. 
°  Crocker.     Diseases  of  the  Skin. 


iii'LMouuiiAdia  \  A  Hie  1:1.1. A  'm:, 

berf^*  as  cases  of  "impo^ti^o  vuriccllosii."  In  m;iiiy  of  the  sfvore 
attacks  of  vjiricclla  certain  vesicles  become  tlic  site  of  iiii|jetigiiiou.s 
sores,  and  (he  patient  recovers  after  somewhat  prolonged  convales- 
cence. In  some  instances  it  has  been  found  dinl  these  lesions  of  the 
skin  cause  infcclioii  cnoufi^h  to  [)njduc(;  fever  f(jr  many  days.  As  a 
result  of  the  infection  of  the  skin  lesions  by  pyogenic  cocci  the 
neighboi-inn;  glands  often  enlarge,  but  they  infrecjuently  su[j[jurate. 

In  connection  with  this  sul)ject  of  impetigitujus  lesions  it  is  well 
to  remember  that  although  this  complication  is  usually  simply 
troublesome,  it  may,  when  neglected  and  when  the  lesions  are 
irritated  by  scratching,  become  serious  and  even  bring  about  the 
death  of  die  patient. 

Dr.  Burvill-Holmes  informs  us  that  he  once  saw,  in  the  infirmarj' 
of  the  Girard  College,  a  boy  ill  of  varicella  who,  although  he  had  but 
few  varicellous  lesions,  was  extremely  ill  as  the  result  of  the  toxaemia 
resulting  from  several  large  areas  of  impetiginous  ulceration.  I'he 
constitutional  symptoms  of  such  a  case  may  be  very  severe  and  the 
fever  remain  high  for  several  days. 

Trousseau^  and  Kaupe''  have  reported  epidemics  of  varicella 
during  which  pemphigoid  blebs  appeared  on  various  portions  of  the 
skin  in  several  patients  and  left  ulcerating  surfaces  not  to  be  dis- 
tinguished from  the  ulcerations  of  true  pemphigus.  These  ulcera- 
tions persisted  for  many  weeks.  Pye-Smith^  and  Freeth'  have 
reported  cases  of  varicella  in  w^hich  bullse  appeared  and  persisted 
much  as  the  above-mentioned  pemphigoid  cases. 

Boils  and  subcutaneous  abscesses  often  occur  during  con- 
valescence from  varicella,  and  are  particularly  prone  to  occur  in 
the  region  of  the  scalp,  although  any  portion  of  the  body  surface 
may  become  involved. 

Hemorrhagic  Varicella. — This  type  of  varicella  is  fortimately 
rare,  although  hemorrhages  not  infi-equently  take  place  in  a  small 
number  of  the  vesicles.     In  the  more  severe  forms,  large  and  small, 


1  Welch  and  Schamberg.     Acute  Contagious  Diseases,  p.  325. 

2  Trousseau.     Lectures  on  Clinical  ^Medicine.  Philadelphia,  1SS2. 

5  Kaupe.      Vierordt,   Penzoldt-Stintzing's    Handbuch    der  speciellen    Therapie    innere 
Krankheiteu,  Band  i,  S.  187. 

■•  Pye-Sniith.     British  Journal  of  Dermatology,  1S97,  xix,  148. 
5  Freeth.     British  Medical  Journal,  March  24,  1906. 


376  VARICELLA 

ecchymoses  appear  under  the  skin  with  petechial  hemorrhages 
into  or  about  the  vesicle.  These  hemorrhages  may  be  accompanied 
by  marked  constitutional  synij)toms,  with  luvmatemesis  and  some- 
times witii  mehvna.  The  symptoms  of  tiiesc  cases  may  be  very 
severe,  but  recovery  usually  takes  place. 

Rundle'  has  reported  a  case  of  hemorrhagic  varicella  in  a  child, 
aged  two  years,  in  wliic  h  the  petechia  and  ecchymotic  spots  were 
scattered  over  many  areas  of  the  body,  while  there  was  also  present 
se\eral  large  ecchymotic  hemorrhages.  This  child  developed  sub- 
conjunctival hemorrhages  and  died  on  the  fourth  day  of  the  illness. 
Porter,-  Beniouilli  and  Baadei,^  Gallianl,'  ('oml)y,'^  Rollcston," 
Ploc,'  Andrews,**  and  others  have  reported  similar  cases,  although 
in  the  majority  of  them  the  symptoms  were  not  severe  and 
recovery  took  place. 

Erysipelas. — Erysipelas  does  not  complicate  varicella  nearly 
so  fret|ucntly  as  would  seem  natural  when  we  consider  the  oppor- 
tunities for  infection.  Fre^'er'  mentions  a  case  of  eiysipelas  migrans 
complicatijig  varicella,  and  Holt^"  mentions  three  fatal  eases  in 
which  varicella  was  complicated  by  erysipelas. 

Fatal  Cases  of  Varicella. — Deaths  as  a  result  of  uncom- 
plicated varicella  are  rare,  but  Fiirbringer'^  and  Nisbet^"  have 
each  reported  an  instance,  while  Aviragnet  and  Apert^^  report  two 
deaths  from  this  disease  in  a  total  of  10  cases  in  a  family  epidemic. 
MacCombie"  had  under  his  care  a  child,  aged  thirteen  months,  in 
which  large  areas  of  the  skin  were  involved,  and  following  the  rup- 
ture of  the  vesicles,  the  epidermis  peeled  off  extensively  and  the  skin 
became  inflamed  and  swollen.     There  was  high  temperature  from 

'  Rundle.     Lancet,  January  16,  190G. 

2  Porter.     Lancet,  May  18,  1907. 

3  Bernouilli  and  Baader.     Corr.  f.  Schweizer  Aerzte,  No.  11,  p.  1880. 

*  Galliard.      In  Brouardel  and  Gilbert's  Traitd  de  M(!-d.,  art.  Varicelle. 
'  Comby.     TraitfS  des  Maladies  de  I'Enfance,  1905. 

*  Rolleston.     Loc.  cit. 

'  Ploc.     Casop.  lek.  cesk.  (v.  Praze,  1898),  37,  pp.  84  to  86. 

*  Andrews.     Clinical  Societies  Tran.sactions,  London,  1890,  xxiii,  79. 
»  Freyer.     Deutsche  med.  Wochenschrift,  1878,  iv.,  Ill  tO  113. 

>o  Holt.     Diseases  of  Infancy  and  Childhood,  p.  978. 

"  Furbringer.  Quoted  by  Gee  in  Reynolds'  System  of  Med.,  original,  v.  Ziemssen's 
Handbuch,  a.  a.  a.,  S.  22. 

'=  Nisbet.     Australian  Medical  Magazine,  1894,  xiii. 

I'  Aviragnet  and  Apert.     In  Cheini.sse's  article,  Semaine  Mddicale,  20,  No.  52. 

'*  MacCombie.     Loc.  cit.,  p.  480. 


1' A  HOT  IT  IS  377 

the  second  (lay  of  ilic  disease,  and  (lie  ehild  died  on  \\\'-  \\\\\  da\-  of 
tli(!  illness. 

It  is  to  l)e  reinenilxTed,  liovvever,  dial  eondiieni  \aiiee||;i  I>  rate, 
particularly  a,inon<i,'  eliildr-en,  and  in  many  eases  is  didi'iill  lo  dis- 
tiiio-iiish  from  variola;  cspceially  is  this  true  wlieri  the  j>ati(tnt  i.s 
seen  late,  that  is,  after  the  ruj)tiire  and  partial  drying  of  the  vesicles. 

Generalized  (Edema. — Generalized  fx^dema  of  die  horly  diirinj( 
varicella  has  been  reported  by  Starck,'  bnl  (Ids,  as  in  several  other 
cases  not(>d,  was  probably  due  to  a  nephritic  conditi(Mi. 

Lymphadenitis.  Siif^-ht  enlargement  of  the  lymph  glands 
occurs  in  nearly  all  cases  of  varicella.  Jyympliadenili^  eoi]i|)li- 
cating  this  disease  has  been  particularly  referred  (>)  by  Lamae(|- 
Dormoy,^  who  reported  his  observations  during  an  ej>idemic,  and 
concludes  that  general  enlargement  of  the  lymphatic  glands  is  the 
rule;  but  he  lays  particular  emphasis  upon  preauricular  and 
mastoid  adenitis,  stating  that  they  were  present  in  every  case  of 
the  disease. 

Pyaemia  as  a  complication  of  varicella  is  a  rare  occurrence,  but 
this  apparent  infrecjuence  may  be  due  to  the  fact  that  the  cases  are 
not  reported.  Brunner^  has  reported  an  interesting  case  of  this 
complication  during  a  severe  attack  of  varicella.  The  child  devel- 
oped a  suppurating  lesion  of  the  elbow-joint,  followed  by  a  double 
parotitis  and  otitis  media  of  the  left  ear.  The  case  ended  fatally 
on  the  ninth  day  of  the  illness.  Autopsy  revealed  the  presence 
of  pus  in  the  anterior  mediastinum,  the  pericardium,  and  in  the 
spleen  and  kidneys.  The  staphylococcus  pyogenes  was  recovered 
from  the  blood,  pus,  and  urine  during  life. 

Parotitis. — Parotitis  has  been  reported  but  few  times  as  a 
complication  of  varicella.  Brunner^  saw  a  case  in  which  both 
parotids  were  involved  in  a  case  that  ended  fatally,  while  one  of  us 
(Beardsley)  saw  a  case  of  unilateral  parotitis  in  the  dispensary  at 
the  Starr  Centre,  in  an  Italian  child,  aged  four  years,  whose  body 
was  still  covered  with  numerous  drying  lesions  of  varicella.     In  this 

1  Von  Starck.     Deutsches  Archiv  f.  klin  Med.,  Leipzig,  1S96,  Ivii,  448. 
-  Lamacq-Dormoy.     Gaz.  Hebdomadaire  des  Sciences  Medicales  de  Bordeaux,  March 
6,  1904. 

3  Brunner.     Quoted  by  Brown,  art.  on  Varicella,  Twentieth  Century  Practice. 
*  Brunner.     Loc.  cit. 


37S  VARICELLA 

case  the  parotid  became  enlarged  dh  the  fourth  day  of  the  illness 
and  coincidentally  with  the  appearance  of  a  bright  red  ervthema 
which  had  faded  in  part  before  the  child  was  brought  to  the  dis- 
pensary. The  parotitis  persisted  for  three  days.  The  erythema, 
which  was  not  accompanied  by  any  other  symptoms,  disappeared 
twelve  hours  after  its  appearance,  and  the  child  became  perfectly 
well. 

Thyroiditis. — Thyroiditis  is  a  very  rare  complication  of  varicella, 
but  Allaria^  has  reported  an  instance  in  which  the  thyroid  became 
inflauied  and  suppurated. 

Laryngitis. — Laryngitis  is  another  rare  complication  of 
varicella,  but  probably  not  as  rare  in  severe  cases  of  the  disease 
as  the  lack  of  references  to  the  complication  would  indicate. 
Marfan  and  Halle"  have  reported  two  cases.  In  the  first  case  the 
dyspncea  was  so  urgent  that  it  was  necessary  to  perform  trache- 
otomy, the  child  making  a  good  recovery.  In  the  second  case, 
which  resulted  fatally,  there  was  found  at  autopsy  a  small  ulcer 
on  the  posterior  surface  of  the  right  vocal  chord,  probably  the  result 
of  an  ordinary  varicellous  vesicle.  Fiirbringer^  has  also  reported 
a  fatal  instance  of  involvement  of  the  larynx  during  varicella. 

Otitis  Media. — Otitis  media  is  a  rare  complication  of  varicella, 
but  has  been  reported  by  Dournel,*  Brunner,^  Lamois,"  and  others. 
I\Ioy^  reports  17  cases  of  otitis  complicating  varicella  in  an  epidemic 
of  875  cases  of  the  disease. 

Mucous  Membranes. — These  are  quite  frequently  the  site  of 
varicellous  lesions.  ^Yelch  and  Schamberg,^  Henoch,"  and  Coste^" 
all  assert  this  fact  and  state  that  lesions  upon  the  buccopharyn- 
geal mucous  membrane,  hard  and  soft  palate,  gums  and  tongue, 
are  frequently  found  and  often  cause  difficulty  in  feeding  the 
patients.      Thomas^^  has  noted  lesions   upon   the  nasal   mucous 

1  AUaria.     Monats.  f.  Kinderheilk,  December,  1903. 

2  Marfan  and  Hall6.     Quoted  by  Brown,  loc.  cit. 

^  Fiirbringer.     Von  Ziemssen's  Handbuch,  a.  a.  o.,  3,  22. 

*  Dournel.     Paris  Thfeses,  1906. 
'  Brunner.     Loc.  cit. 

»  Lamois.     Rev.  Hebd.  de  Laryngol.,  Paris,  1904,  i,  105  to  109. 
'  Moy.     Theses  de  Lyon,  1906-1907,  No.  53. 

*  Welch  and  Schamberg.     Loc.  cit.,  p.  327. 

'  Henoch.     Berliner  klin.  W'ochenschrift,  January  14,  1884,  No.  2. 
•o  Coste.     Marseille  M^d.,  January,  1908. 
"  Thomas.     Loc.  cit.,  vol.  ii. 


BRONCHITIS  AND  JiUOSCIiOi'S  ICII  MOM  A  ;J70 

memhnincs,  while  lesions  iirc  somcfinics  seen  upon  llic  nin'ous 
inenibnine  of  tlic  vaninii  iiiid  \)vv\n\vv  jind  in  these  situations  soine- 
tinies  eaiise  (lidiciiity  and  pain  on  nrinalion.  Cofjmhs'  has  re- 
ported a  case  in  which  variccllons  lesions  npon  tlif  [)r(f)uce  caused 
such  sweliinfif  that  retention  of  urine  resulted.  Jn  this  ease  there 
seemed  to  be  one  or  more  lesions  within  the  urethra  about  one 
inch  from  the  orifice.  There  was  pain  on  urination  for  several 
days  and  slight  swelling-  and  induration  about  tiiis  porlion  of  the 
urethra. 

Bones  and  Joints.  Synovitis  and  arthritis  have  been  reported 
as  rare  complications  of  this  disease.  Laudon^  and  Perret'  have 
both  reported  examj)les  of  these  complication.  Laudon's  patient 
was  a  boy,  aged  four  years,  who  developed  high  fever  early  in  the 
course  of  the  disease  and  later  there  developed  a  marked  swelling  of 
the  left  elbow-joint.     Recovery  followed. 

Semtschenke''  saw  two  patients  who  suffered  from  purulent 
arthritis  during  the  course  of  varicella.  Hogyes"  reports  the  case 
of  a  girl,  aged  seven  years,  who  after  an  attack  of  varicella  devel- 
oped nephritis  and  subsequently  a  polyarticular  arthritis  accom- 
panied by  high  fever.  This  patient  recovered.  Braquehaye"  saw^ 
a  case  of  arthritis  complicating  varicella,  which  developed  on  the 
ninth  day  of  the  illness  and  which  resulted  in  death  despite  incision 
and  drainage.     At  autopsy  a  septic  endocarditis  was  discovered. 

Periostitis  of  the  femur  as  a  complication  of  varicella  has  been 
reported  by  Steiner,^  and  the  same  complication  affecting  the 
humerus  was  reported  by  Brunner.^ 

Bronchitis  and  Bronchopneumonia. — These  conditions  are  rare 
complications  of  varicella.  PowelP  and  Partridge^'^  have  both 
reported  instances  of  bronchopneumonia  fatal  in  the  course  of 
varicella,  while  MacCombie"  has  seen  both  bronchitis  and  broncho- 

1  Coombs.     British  Medical  Journal,  March  18,  1905. 
^  Laudon.     Deutsche  med.  Wochenschrift,  Leipzig.  1890,  xvi,  576. 
^  Perret.     Province  med.,  Lyon,  1899,  iii,  256  to  261. 
^  Semtschenke.     Wiener  klin.  Wochenschrift.  18S9.  quoted  by  Rille. 
'  Hogyes.     Jahrbuch  f.  Kinderheilk.,  X.  F.,  Band  xxiii,  S.  337. 
^  Braquehaye.     Quoted  by  Welch  and  Schamberg.  loc.  cit.,  p.  231. 
^  Steiner.     W^ien.  med.  Wochenschrift,  1875. 
5  Brunner.     Loc.  cit. 

'  Powell.     International  Clinics,  January,  1S97. 

1°  Partridge.     Exhibited  patient  at  New  York  Pathological  Society,  18S7. 
"  MacCombie.     Loc.  cit.,  p.  482. 


3S0  VARICELLA 

pneumonia  coniplic-ate  the  disease  in  ^veakly  infants.  Rille' 
has  notetl  a  case  of  varicelhi  complicated  bv  "pleuropneumonia" 
wliicli  resulted  fatally  on  the  nineteenth  day  after  the  onset  of  vari- 
cella. Marfan  and  Hall^,'  as  well  as  Ilogyes''  and  Eustace  Smith,' 
have  all  met  with  cases  of  varicella  complicated  hy  pneumonia. 

Pleurisy. — This  com[)lication  has  been  noted  by  but  few 
observers.  Rille'"  and  Semtschenke"  have  both  observed  cases  of 
varicella,  complicated  by  pleurisy,  during  epidemics  of  the  former 
disease. 

Nervous  Complications. — These  complications  during  the 
course  of,  and  during  the  convalescence  from,  varicella  are  rare, 
but  are  exceedingly  interesting. 

Encephalitis,  meningitis,  paraplegia,  monoplegias,  and  various 
paralyses  of  the  muscles  of  the  eye  have  been  reported  by  various 
observers. 

Caccia^  has  reported  a  case  which  developed  encephalitis  second- 
ary to  a  severe  attack  of  varicella,  Rossi*  has  made  mention  of  a 
right  bronchial  monoplegia  which  developed  during  convalescence 
from  varicella. 

MacComl)ie^  states  that  one  of  the  children  under  his  care  had 
an  attack  of  varicella  which  was  complicated  by  paraplegia.  This 
condition  became  gradually  improved  some  weeks  after  convales- 
cence from  the  original  disease.  Gay,  in  1894,  also  reported  this 
complication.  It  is  to  be  remembered  that  those  cases  of  varicella 
developing  otitis  media  are  prone  to  also  develop  mastoiditis, 
meningitis,  cerebral  abscess. 

Nephritis. — Although  albuminuria  and  nephritis  are  both 
rare  complications  of  varicella,  it  is  quite  likely  that  if  the  urine 
of  the  patients  suffering  from  the  disease  was  carefully  examined 
albumin  would  be  discovered  much  more  frequently  than  is  usually 
thought. 

When  nephritis  does  develop  it  is  one  of  the  most  dangerous 
complications  of  varicella. 

'  Rille.      Deutsche  med.  Wochenschrift,  1891. 

2  Marfan  and  Hallf?.     Loc.  cit.  '  Hogyes.     Loc.  cit. 

■*  Eustace  Smith.     Diseases  in  Children,  p.  49.  ^  Rille.     Loc.  cit. 

^  Semtschenke.     Loc.   cit. 

^  Caccia.     Riv.  de  Clin.  Pediat.,  November,  1904. 

8  Rossi.     Gaz.  degli  Osped.,  1903,  N.  43.  »  MacCombie.     Loc.  cit.,  p.  482. 


'      VAJi/CJ'JLLA    IN   ADIII/r   LIFE  v,Sl 

ITcnocli'  Wiis  one  of  llur  first  to  cnll  iiltciilioii  (o  flic  rir-j;liriti.s 
following  vuricella,  and  lie  reported  four  eases  of  this  eoii)j>l)e;iiif>ri. 
Other  writers,  notahly  voii  Jurf^enseii,''  linmncc,'  iJillr-,'  ;ind 
Dillon  Brown/'  have  also  reported  this  eomjilieafioii,  ;iiid  fidlffj 
attention  to  the  necessity  of  watchful  care  as  to  th(;  slate  of  ihe 
kidney  both  during  and  following  the  attack  of  vai'icella. 

The  inflammation  of  the  kidney  usually  occurs  during  tlu  first 
or  second  week  of  the  disease,  and  varies  in  severity  witli  (Ik- degree 
of  toxa3mia  and  the  resistance  of  the  tissues  of  the  patient.  As  a 
rule,  the  nephritis  is  mild,  recoveiy  taking  place  promptly;  but 
without  doubt,  some  of  the  cases  are  prolonged  and  may  cause 
death  months  after  the  primary  disease.  Dillon  Brown"  has 
reported  such  a  case  in  wliich  the  kidney  involvement  following 
a  mild  attack  of  varicella  ran  a  chronic  course,  ending  fatally 
some  ten  years  later. 

Hogyes^  has  recorded  a  case  of  varicella  which  was  complicated 
by  pneumonia  and  nephritis,  and  also  terminated  fatally,  while 
Rille  reports  a  case  of  varicella  complicated  only  by  nephritis, 
which  ended  in  death,  and  at  the  autopsy  parenchymatous  changes 
were  found  in  both  kidneys.  One  of  us  (Beardsley)  has  recently 
studied  a  case  of  varicella,  in  a  child  six  years  of  age,  that  devel- 
oped albuminuria  and  casts  on  the  third  day  of  the  eruption. 
The  casts  disappeared  after  six  days,  but  albuminuria  persisted 
for  two  weeks. 

Varicella  in  Adult  Life, — Varicella  is  considered  by  many 
physicians  to  be  a  disease  of  childhood  only,  and  many  writers 
of  experience  state  that  they  have  never  observed  a  case  of  the 
disease  in  an  adult. 

Thomas,  whose  experience  was  extensive,  states  that  he  had 
never  seen  the  disease  in  an  adult,  while  von  Jurgensen^  remarked 
that  varicella  was  a  disease  peculiar  to  childhood.  On  the  other 
hand,  Lys"  has  seen  three  cases  in  the  same  family,  all  in  adults,  and 


1  Henoch.     Loc.  cit. 

-  Von  Jurgensen.     In  Nothnagel's  Encyclopaedia  of  Medicine  (Varicella). 

3  Brunner.     Loc.  cit.  <  Rille.     Loc.  cit. 

^  Dillon  Brown.     Loc.  cit.  s  Dillon  Brown.     Loc.  cit. 

"^  Hogyes.     Loc.  cit.  s  Von  Jurgensen.     Loc.  cit. 

«  Lys.     Lancet,  May  12,  1S83. 


382  VARICELLA 

Bohn'  lias  also  reported  a  case,  while  Tripolcp  has  observed  34 
cases  in  adults  during  a  large  epidemic  of  the  disease, 

Wanklyn^  reports  33  cases  in  patients  over  eighteen  years  of  age, 
seen  in  two  years  at  the  diagnosticating  station  in  London. 

Welch  and  Schanibei'g"'  also,  whose  experience  and  whose  oppor- 
tunities iov  (^l)servation  have  been  second  to  none,  state  tiiat  within 
a  period  of  eighteen  months  they  had  observed  no  less  than  IG  cases 
of  varicella  in  adults,  while  in  the  last  thirty-two  years  there  had 
been  admitted  to  the  Municipal  Hospital  of  Philadelphia  35  cases 
of  varicella  in  adults.  One  of  us  (Beardsley)  had  under  his  care  a 
few  years  ago  a  physi(>ian,  aged  about  forty  years,  who  came  from 
the  West  to  attend  the  meeting  of  the  American  Medical  Associa- 
tion in  Atlantic  City.  During  the  convention  he  developed  a 
rash  so  universal  and  symptoms  so  unusually  severe  that  although 
the  junior  author  had  recently  enjoyed  eight  months'  observation 
of  smallpox  at  the  Municipal  Hospital,  he  was  very  glad  to  shift 
the  responsibility  of  confirming  the  diagnosis  of  varicella  upon 
Dr.  Welch,  of  the  Board  of  Health  of  Philadelphia.  Dr.  Welch, 
after  a  careful  study  of  the  case,  decided  that  it  was  a  case  of 
true  varicella,  but  one  of  the  most  marked  cases  that  he  had  ever 
seen. 

Second  Attacks. — Second  attacks  of  varicella  are  of  gieat 
rarity.  Neale'  reports  a  second  attack  after  a  period  of  ten  days, 
and  Vetter**  also  states  that  he  has  seen  a  similar  case  in  which 
the  eruption  appeared  fourteen  days  after  the  first  eruption  had 
disappeared.  Many  physicians  whose  interest  lies  particularly  in 
contairious  diseases  have  never  seen  a  second  attack  of  the  disease. 
The  two  cases  quoted  above  might  more  truthfully  be  termed 
relapses. 

Scarring  after  Varicella. — It  is  usual  to  find  some  slight  scar- 
ring after  a  severe  attack  of  varicella,  and  after  a  severe  attack 
the  scarring  is  usually  more  marked  than  in  a  case  of  modified 
variola. 

>  Bohn.     Quoted  in  von  Ziem?«en's  Cyclopaedia  of  Medicine. 

STripold.     Med.  Klinik.  1908,  No.  34. 

'  Wanklyn.     British  Medical  Journal,  July  5,  1902. 

*  Welch  and  Schamberg.     Loc.  cit.,  p.  327. 

'  Neale.     Lancet,  1891,  No.  2. 

6  Vetter.     Quoted  by  Welcli  and  Schamberg,  loc.  cit.,  p.  319. 


S(JAkh'/N(J  Ah'TICh'.    V auk: ELLA  p^^^ 

Occa,yi(>iially  keloid  growUis  an;  ohscrvwJ  al.  the  .si((;  f^f  tlic 
scarring.  Scleroderma  following  vjiricella  has  fx^eri  j'e|;orted  by 
Bouvy/  and  scroriiloliilxTciilosis  of  (lie  skin  hy  J''oiil;iid.'"' 

1  Boiivy.      .IdNnijil  ill'  din.  ct,  (\c  IhrTiip.  inf.,  IHOH,  vi,  480  to  4Hi). 
^  Foiilanl.      Ann.  dc  ilciiri.  (;l  do  l;i  .Hypli.,  1890,  vii,  :',l,2. 


CHAPTER    V. 

RUBELLA. 

Rubella,  or  German  inea:sles,  sometimes  called  epidemic 
roseola,  is  the  mildest  of  the  acute  exanthemata  and  least  likely  to 
have  troublesome  complications  or  sequels.  When  these  occur 
they  are  usually  characterized  by  catarrhal  processes.  Bronchitis 
and  pneumonia,  which  are  such  common  complications  of  true 
measles,  are  rarely  met  with  in  rubella,  and  when  they  occur  usually 
develop  in  children  who  are  primarily  of  low  vitality.  In  conse- 
quence, we  find  that  the  complications  and  sequels  of  rubella  are 
much  more  frequently  met  with  in  orphan  asylums  and  institu- 
tions for  poor  children  than  they  are  in  private  practice.  In 
the  latter  class  of  cases  complications  arise  almost  solely  as  the 
result  of  unnecessary  exposure,  and  rarely  in  children  that  are 
properly  cared  for.  In  other  words,  the  disease  by  slightly  impair- 
ing the  patient's  vital  resistance  lays  him  open  to  conditions  which 
arise  from  exposure.  Even  in  institutions,  however,  pneumonia 
rarely  occurs,  either  in  the  course  of  or  as  a  sequel  to  rubella.  In 
166  cases,  Edwards*  met  with  only  three  which  were  complicated 
by  pneumonia,  and  Griffith^  met  with  only  two  cases  of  pneiunonia 
in  150  cases  of  rubella.  So,  too,  Cheadle,^  Smith,^  Earle,'^  and 
Park,®  although  they  all  met  with  bronchitis  and  pneumonia 
complicating  severe  cases  of  rubella,  note  its  infrequency. 
Klaatsch^  quotes  Kronenberg,  who  states  that  bronchitis,  pneu- 
monia, and  cerebral  congestion  caused  four  deaths  in  patients 
under  his  care. 

1  Edwards.     Keating's  Cyclopaedia  of  Diseases  of  Children,  p.  687. 

2  Griffith.     New  York  Medical  Record,  July  9,  1887,  p.  39. 
'  Cheadle.     International  Med.  Cong.,   1881,  iv,  4. 

*  Smith.     Diseases  of  Children,  1879,  p.  191. 
'  Earle.     St.  Louis  Medical  and  Surgical  Journal,  1881,  xli.  392. 
°  Park.     Chicago  Medical  Journal  and  Examiner,  1881,  xliii,  130. 
"  Klaatsch.     Zeitsch.  f.  klin.  Med.,  Band  x.  Heft  1,  S.  1. 


RUBELLA  385 

Pleurisj/  juul  emjyjjema  arc  exticiricly  rare  (■ornplications,  but 
Ryle*  and  J^'.dwaTds''  each  saw  a  case  which  developed  empyema 
during  the  course  of  a  severe  attack  of  rubella. 

NasopJiari/iK/rdl  ralarr/i  willi  priuuiry  and  secoiKhuy  son;  throat 
are  very  troublesome  coinpiications  during  e[)ideniirs  of  a  severe 
type.  Tonge-Smith,''  P^mminghaus/  ?]usta(;e  Smifh,''  and  other 
observers  have  re|)oi-ted  cases  of  secondary  s(jre  thi-oat  as  compli- 
cations of  rubella,  while  Cheadle,"  Lublinski/  Atkinson,"  and 
Mettenheiraer  have  reported  tonsillitis  occurring  as  a  complica- 
tion or  sequel  to  an  attack. 

Throat  Comjilkaiions. — Sore  throat  of  a  mild  character  is  a  very 
common  symptom  of  rubella,  and  we  have  already  spcjken  of  the 
primary  and  secondary  sore  throats  which  may  occur  and  which 
may  be  very  severe.  Hoarseness,  usually  mild  in  character,  but 
occasionally  severe,  has  been  noted  by  many  observers  during  the 
early  stage  of  the  disease,  and  may  pei-sist  for  several  days,  although 
it  commonly  disappears  with  the  disappearance  of  the  eruption. 

Stomatitis  is  a  frequent  complication  during  epidemics  of  rubella, 
and  varies  in  intensity  from  a  mild  catarrhal  inflammation  to  the 
rare  ulcerative  form.  Edwards^  noted  stomatitis,  of  varying  grades 
of  severity,  thirty  times  in  his  series  of  166  cases.  Hatfield'"  and 
Earle'^  have  both  reported  instances  of  this  complication. 

Parotitis  is  a  very  rare  complication  of  rubella,  but  has  been 
reported  by  Roth.^^ 

Thyroid  enlargement  occurs  in  this  disease,  as  it  does  in  neaj-ly 
all  the  acute  infectious  diseases,  but  much  more  rarely  than  in  any 
of  the  others.  SlageP^  has  reported  a  painful  enlargement  of  this 
gland  in  six  cases  of  rubella  under  his  care. 

'  Ryle.     British  Medical  Journal,  1886,  ii,  160. 

"  Edwards.     American  Journal  of  the  Medical  Sciences,  1884,  p.  484. 

3  Tonge-Smith.     Lancet,  1883,  i,  994,  1036. 

*  Emminghaus.     Loc.  cit. 

^  Eustace  Smith.     Diseases  of  Children,  p.  31. 

^  Cheadle.     International  Medical  Congress,  1881,  iv,  4. 

7  Lublinski.     Med.  Klinik.,  1907,  No.  52. 

8  Atkinson.     American  Journal  of  the  Medical  Sciences,  Januarj',  1887. 
^  Edwards.     Loc.  cit. 

'"  Hatfield.     Chicago  Medical  Examiner,  August.  1881. 

n  Earle.     St.  Louis  Medical  and  Surgical  Journal,  1881,  xli,  392. 

12  Roth.     Quoted  by  Welch  and  Schamberg.  Acute  Contagious  Diseases. 

13  Slagel.     Trans.  Minnesota  Med.  Cong.,  1881,  p.  204. 
25 


3S6  RUBELLA 

Gasiro-inlcsiinal  Disturbances. — Altboiioh  the  usual  case  of 
lubella  does  not  show  signs  of  gastro-inlestinal  irritation,  in  severe 
epidemics  these  disturbances  may  cause  great  difficulty.  In  40 
per  cent,  of  Edwards'^  cases  symptoms  of  gastro-intestinal  irritation 
were  presejit,  and  in  five  of  this  series  vomiting  was  a  persistent 
and  troublesome  feature.  Welch  and  Schamberg'  report  a  case 
under  their  care,  at  the  Municipal  Hospital  of  Philadelphia,  in 
which  vomiting  persisted  for  several  days  before  the  appearance 
of  the  rash.  Griffith^  states  that  vomiting  occurred  in  several  of 
his  severe  cases.  Diarrhoea  is  a  not  infrequent  symptom  of  the  more 
severe  attacks  of  rubella,  but  the  milder  attacks  seldom  show  this 
symptom.  Cuomo,*  Earle,^  and  Balfour"  found  enterocolitis  a 
common  symptom  in  some  severe  cases  of  rubella,  but  most  writers 
upon  rubella  consider  enterocolitis  a  rare  complication. 

General  lymphatic  enlargement  has  long  been  regarded  as  a  sign 
of  much  importance  in  the  diagnosis  of  rubella,  and  particularly 
has  this  been  true  of  the  glands  behind  the  ears  and  those  lying 
posterior  to  the  sternocleidomastoid  muscle.  Maton,''  as  long  ago 
as  1815,  pointed  out  the  importance  of  these  enlarged  glands,  and 
Thierfelder^  and  Atkinson,®  as  well  as  other  WTiters,  point  out  that 
the  enlargement  of  the  glands  of  the  neck  is  a  constant  prodromal 
symptom,  and  may  attract  attention  several  days  before  the  appear- 
ance of  the  rash.  Emminghaus,^"  on  the  other  hand,  states  that  the 
glandular  enlargement  may  be  slight  and  subside  before  the  appear- 
ance of  the  rash. 

Corlett"  states  that  96  per  cent,  of  his  cases  showed  the  glandular 
enlargement.  The  maxillary  and  superficial  cervical  glands  were 
most  commonly  involved;  next  the  occipital,  posterior  and  anterior 
auricular,  and  sometimes  the  inguinal,  axillary,  and  epitrochlear 
glands.     Corlett  also  states  that  the  swelling  from  the  inflammation 

'  Edwards.     Loc.  cit. 

^  W^elch  and  Schamberg.     Loc.  cit. 

'  Griffith.     Medical  Record,  July  9,  1887,  p.  39. 

■•  Cuomo.     Gior.  internaz.  d.  sc.  med.,  Napoli,  1884,  vi,  529. 

*  Earle.     Loc.  cit. 

6  Balfour.     Edin.  Med.  Jour.,  1856-57,  p.  717. 

'  Maton.     Med.  Trans.  College  of  Physicians,  London,  1815,  v,  149. 

*  Thierfelder.     Greifsw.  med.  Beitr.,  1864,  Band  ii,  Berlin,  p.  14. 

*  Atkinson.     Loc.  cit. 

"  Emminghaus.     Loc.  cit. 

"  Corlett.     A  Treatise  on  the  Acute  Infectious  Exanthemata,  p.  356. 


CUTANJ'JOUS  LJ'JSIONS  387 

of  tlic  gliuids  of  the  neck  may  ho  siifriciciit  to  liinit  Uic  motion  of  the 
nock,  and  in  a  lew  cases  it  has  cansed  a;dema  of  tlie  tissues,  Musser' 
noted  tumefaction  of  the  inguinal  glands  in  several  of  his  cases,  and 
also  saw  the  same  state  of  the  axillary  glands  less  often,  Golson' 
has  reported  a  unicjuc  complication  of  rubella  in  reporting  a  case 
of  abscess  of  the  su))ma.\illary  glancJ  during  convalescence  from 
this  disease.  Eustace  Smith'  and  Kassowitz*  are  of  the  opinion 
that  in  certain  epidemics  of  rubella  the  glandular  enlargement  is 
not  seen,  or  at  least  occurs  in  only  a  small  percentage  of  the  cases 
Park''  met  with  glandular  enlargement  in  but  50  per  cent,  of  his 
cases,  but  Klaatsch"  declares  that  this  sign  is  so  constant  that  the 
diagnosis  may  be  made  from  this  alone. 

Cutaneous  Lesions. — Urticaria  has  been  observed  to  complicate 
the  onset  of  rubella  by  Musser,^  Slagle,®  Earle,''  and  Cullingworth.*^ 
Griffith"  noted  among  his  cases  an  eruption,  which  gave  a  shotty 
feel  to  the  palpating  finger,  and  Davis  reports  a  case  of  rubella 
with  a  purple  rash.  There  have  been  reported  by  various  writers 
instances  in  which  the  rash  of  rubella  closely  resembled  that  of 
scarlet  fever,  and  these  cases  have  been  designated  as  the  "scarla- 
tiniform  variety"  of  rubella.  Griffith, ^^  who  has  studied  a  large 
number  of  cases,  concludes  that  there  are  two  easily  recognized 
types  of  variation  from  the  normal  character  of  the  rash  in  rubella : 

1,  "An  eruption  in  which  the  spots  are  for  the  most  part  nearly 
or  fully  the  size  of  a  split  pea,  more  or  less  grouped  and  having  a 
great  resemblance  to  measles. 

2.  "A  rash  which  is  confluent  in  patches  or  universally  not 
elevated,  and  which  produces  a  uniform  redness  closely  simulating 
that  of  scarlatina,  but  a  very  careful  examination  will  often  reveal  a 
few  papules  amid  the  general  diffuse  redness." 

^  Musser.     Quoted  by  Griffith,  loc.  cit. 

*  Golson.     Transactions  of  the  Medical  Association  of  Alabama,  1SS3. 
'  Eustace  Smith.     Loc.  cit. 

*  Kassowitz.     Transactions  of  the  International  Congress,  ISSl,  iv,  10. 
^  Park.     Chicago  Medical  Journal  and  Examiner,  1881,  xliii,  130. 

6  Klaatsch.     Zeitschr.  f.  khn.  Med.,  Band  x,  Heft  1,  S.  1. 
^  Musser.     Loc.  cit. 
'  Slagle.     Loc.  cit. 
'  Earle.     Loc.  cit. 

10  Cullingworth.     British  Medical  Journal,  18S3,  ii,  1234. 

11  Griffith.     Loc  cit. 

12  Griffith.     Loc.  cit. 


388  RUBELLA 

Dunlop'  and  Chcadle"  have  each  reported  an  instance  of  petechial 
hemoirliaije  into  the  cutaneous  lesions,  but  this  comph'cation  is 
exceedingly  rare.  Ei'skine^  noted  })etefhial  lesions  upon  the  uvula 
and  soft  palate  of  one  case,  and  Glaiser^  mentions  that  he  saw  a  case 
of  rubella  with  a  purpuric  rash.  Miliary  vesicles  during  the  course 
of  the  disease  and  furunculosis  during  convalescence  have  been 
noted  by  various  observers,  but  are  rare.  Pemphigus  has  also 
been  seen  during  convalescence.  Douglas^  and  Griffith®  and  Thier- 
felder^  both  noted  oedema  of  the  face,  concurrent  with  the  appear- 
ance of  the  eruption  in  several  cases.  Emminghaus^  noted  a*dema 
of  the  extremities  in  one  of  his  cases. 

Eri/sipclas. — This  is  a  rare  complication,  but  has  been  reported 
as  a  se(|uel  to  the  disease  by  Alexander." 

Jaundice  is  a  unique  symptom  of  rubella,  but  was  noted  in  one  of 
the  cases  seen  by  Musser. 

Roughness  of  the  skin  during  rubella  has  been  noted  by  Golson,^" 
Shoemaker,^^  Musser,^^  and  Griffith.'^  This  condition  resembling 
cutis  anserina  may  precede,  accompany,  or  even  persist  for  a  few 
days  after  the  rash  of  rubella  has  disappeared. 

Eye  complications  are  rare  in  rubella,  but  conjunctivitis,  bleph- 
aritis, and  keratitis  have  been  infrequently  reported.  Hardaway" 
has  reported  ciliary  blepharitis  during  a  severe  attack  of  the  disease, 
and  de  Schweinitz^''  has  seen  two  cases  of  phlyctenular  keratitis. 

Ear  complications  are  also  uncommon,  but  Hardaway"  has 
reported  a  case  of  otitis  media.  Cheadle"  states  that  "earache" 
often  developed  among  his  patients  as  the  rash  subsided. 

1  Dunlop.     Lancet,  1871,  ii,  464. 

-  Cheadle.     Loc.  cit. 

'  Erskine.     Lancet,  1880,  ii,  452. 

*  Glaiser.     Transactions  of  tlie  International  Medical  Congress,  1881,  iv,  31. 

<>  Douglas.     Lancet,  1877,  i,  784. 

'  Griffith.     Loc.  cit. 

^  Thierfelder.     Loc.  cit. 

'  Emminghaus.     Loc.  cit. 

'  Ale.xander.     Canada  .Journal  of  the  Medical  Sciences,  1882,  p.  297. 

'"  Golson.     Loc.  cit. 

"  Shoemaker.     Quoted  by  Griffith,  loc.  cit. 

'-  Musser.     Loc.  cit. 

'3  Griffith.     Loc.    cit. 

'<  Hardaway.     St.  Louis  Courier  of  Medicine,  1881,  p.  83. 

'5  de  Schweinitz.     Quoted  by  Griffith,  loc.  cit. 

'^  Hardaway.     Loc.  cit. 

1'  Cheadle.     Loc.  cit. 


ALBUMINURIA  380 

Arthritis  or, synovitis,  or,  us  more  coiiinioiily  .shifcd,  "  rlHiiiri;i- 
tism,"  (liiriiif^  nihelhi  is  a  very  unusual  (•oiu}>lication — so  ran;,  in 
fact,  that  its  occirronce  may  woll  \n\  taken  for  a  coincidt^nce. 
SlageP  observed  tliis  eomj)lieation  once  during  the  disease,  and 
Edwards^  twice,  but  p]arle^  observed  several  cases. 

Convulsions  and  delirium  in  the  course;  of  rubella  .'ii-e  altn(<st 
never  seen  at  the  present  day,  but  have  been  reported  by  Aitken,* 
Patterson^  and  other  writers  of  that  time.  Vei-y  rarely,  indeed, 
rubella  is  ushered  in  by  a  convulsion,  and  in  those  ca.ses  delirium 
is  sometimes  noted. 

Hemorrhage  from  the  eyes  and  ears  has  been  recorded  by 
Prioleau." 

Endocarditis  has  been  met  with  in  but  very  few  instances,  and 
then  only  as  a  complication  in  connection  with  a  severe  synovitis 
during  rubella,  and  we  have  been  unable  to  find  any  reference  to 
any  case  of  pericarditis  occurring  during  the  course  of  rubella. 

Albuminuria. — ^This  is  also  a  rare  complication  of  rubella. 
Hatfield^  found  albumin  in  the  urine  of  but  two  cases,  w^hile  Cuomo^ 
had  three  patients  which  showed  this  symptom.  Kingsley," 
Cheadle,^"  Duckworth,"  and  Reed^^  each  record  a  case  which 
showed  this  symptom. 

Livehng,^^  however,  states  that  albuminuria  is  not  infrequent,  and 
Edwards"  states  that  it  was  present  in 30  per  cent,  of  his  series  of  166 
cases.  An  interesting  fact  in  this  connection  is  that  in  another  series 
100  cases  studied  by  Edwards  only  3  per  cent,  of  the  cases  had 
albuminuria.  In  the  first  series,  nine  cases  showed  well-marked 
albuminuria  associated  with  dropsy.     In  none  of  these  cases  were 


'  Slagel.     Loc.   cit. 

-  Edwards.     Loc.  cit. 

3  Earle.     Loc.  cit. 

^  Aitken.     Science  and  Practice  of  Medicine,  third  American  edition,  1S72,  p.  454. 

'  Patterson.     Edinburgh  Medical  and  Surgical  Journal,  1S40,  p.  381. 

^  Prioleau.     Quoted  by  "Welch  and  Schamberg. 

7  Hatfield.     Loc.  cit. 

8  Cuomo.     Loc.  cit. 

5  Kingsley.     St.  Louis  Courier  of  Medicine,  1S80,  p.  21. 
10  Cheadle.     Loc.  cit. 
»  Duckworth.     Lancet,  ISSO,  i,  395. 

1=  Reed.     Philadelphia  Medical  Times,  November  14,  1SS3. 
13  Liveling.     Lancet,  1874,  i,  360. 
1^  Edwards.     Loc.  cit. 


390  RUBELLA 

tube  casts  found.  Forchheimer'  has  reported  the  death  of  a  child 
as  the  result  of  an  attack  of  rubella  complicated  by  nephritis. 

Mortality. — It  is  extremely  rare  to  have  death  result  from  rubella. 
The  great  majority  of  writers  state  tiiat  death  never  results,  but 
there  can  be  no  doubt  that  severe  cases  do  occur  and  death  results 
from  com])lications  of  the  disease.  Deaths  are  most  likely  to  occur 
during  epidemics  in  orphan  asylums  and  children's  hospitals 
that  are  overcrowded.  Hemin,-  Alexander,^  Cuomo/  Slagle/ 
Roberts,"  Davis/  and  Forchheiraer^  have  each  reported  deaths 
during  an  attack  of  rubella,  usually  as  a  result  of  the  pulmonary 
complications.  Edwards®  had  a  mortality  of  4.5  per  cent,  in  a 
series  of  150  cases  in  a  hospital.  There  were  five  deaths  in  165 
cases.  Two  died  of  pneumonia  and  enteritis,  two  of  enterocolitis, 
and  one  as  the  result  of  tuberculous  meningitis.  Hatfield^**  records 
a  mortality  of  9  per  cent,  in  a  series  of  cases  whose  surroundings 
were  unfavorable  for  recovery. 

Relapse. — ^A  relapse  following  an  attack  of  rubella  is  very 
unusual,  but  competent  observers  have  recorded  instances.  Em- 
minghaus"  reports  such  a  relapse  in  3  cases,  and  Earle^^  in  2. 
Edwards, ^^  in  his  large  experience,  noted  a  relapse  but  twice,  once 
on  the  fourth  and  once  on  the  twentieth  day.  Griffith"  also  observed 
three  relapses.  One  occurred  at  the  end  of  eleven  days  and  two 
others  after  a  period  of  three  weeks.  The  recurrent  attack  may 
equal  the  original  attack  in  intensity,  or  may  be  milder  in  character. 
We  have  been  unable  to  find  an  authentic  case  recorded  of  a  true 
second  attack  of  rubella,  that  is,  an  attack  due  to  a  second  infection 
and  occurring  months  or  years  after  the  primary  attack. 


^  Forchlieimer.     Twentieth  Century  Practice  of  Medicine,  1898,  xiv,  183. 

-  Hemin.     Edinburgh  Medical  Journal,  1880,  xxvi,  52. 

^  Alexander.     Loc.  cit. 

■•  Cuomo.     Loc.  cit. 

°  Slagle.     Loc.  cit. 

6  Roberts.     Southern  Practitioner,  1885,  vii,  402. 

"  Davis.     British  Medical  Journal,  1880,  ii,  507. 

s  Forchlieimer.     Loc.  cit. 

^  Edwards.     Loc.  cit. 

10  Hatfield.     Loc.  cit. 

1'  Emminghaus.     Loc.  cit. 

'-  Earle.     Canadian  Journal  of  the  Medical  Sciences,  1882,  p.  927. 

''  Edwards.     Loc.  cit. 

i<  Griffith.     Loc.  cit. 


AGE  301 

Age. — Children  imdcr  six  yciirs  oi"  ;i^^(;  usually  escape  infection 
by  rubella,  even  wlu'n  exf)0.sed,  alllioiif^li  this  is  not  invariably 
true.  Smith/  Jloth,'-*  Steiner,''  and  Ilardaway^  have  reported  eases 
in  young  infants,  while  Scholl'^  observed  a  case  in  a  baby  a  few  days 
old.  It  is  true  in  rubella,  as  it  is  in  measles,  that  those  who  escape 
the  infection  in  their  childhood  may  contract  it  in  adult  life. 

Seitz"  has  recorded  a  case  in  a  woman,  aged  seventv-three  years, 
who  contracted  rubella  from  a  grandchild.  Ii)mminghaus^  saw 
but  two  adults  attacked  among  42  jjersons  exposed.  Thomas* 
reports  3  among  77  persons  exposed.  Kassowitz"  records  o  in  a 
series  of  64  cases  and  Thomas^^  but  1  in  a  second  series  of  \Ui) 
cases.  Forchheimer,"  on  the  other  hand,  states  that  it  has  been 
his  experience  that  more  physicians  are  attacked  by  rubella  than 
by  all  the  other  exanthematous  diseases  taken  together,  and  it  is 
his  impression  that  adults  were  notably  susceptible  to  the  infection. 

1  Smith.     Loc.  cit. 

-  Roth.     Loc.  cit. 

'  Steiner.     Quoted  by  Welch  and  Schamberg. 

^  Hardaway.     Loc.  cit. 

5  Scholl.     Transactions  of  Medical  Association  of  Alabama,  1881,  p.  528. 

*  Seitz.     Quoted  by  Welch  and  Schamberg,  loc.  cit.,  p.  550. 
■"  Emminghaus.     Loc.  cit. 

*  Thomas.     In  von  Ziemssen's  Cyclopaedia  of  Medicine,  1875,  v,  2. 
8  Kassowitz.     Loc.  cit. 

1°  Thomas.     Loc.  cit. 

'1  Forchheimer.     Loc.  cit. 


INDEX. 


Abdomen,  pain  in,  in  enteric  fever,  135 
and     thorax,     a-dema     of,    after 
enteric  fever,  2()2 
"Abdominal      catarrli"      or     enteric 
fever,  73 
complications    during    smallpox, 
312 
Abscess  of  brain  in  measles,  365 
in  chicken  pox,  375 
in  enteric  fever,  176 
glandular,  in  measles,  361 
hepatic,  in  enteric  fever,  216 
intracranial,  in  measles,  365 
of  kidney  in  smallpox,  312 
of  liver  in  enteric  fever,  216,  219 

in  smallpox,  312 
of  lungs  in  enteric  fever,  191 
postpharyngeal,  in  smallpox,  311 
retro])haryng('al,  in  measles,  357 

in  scarlet  fever,  333 
in  scarlet  fever,  317 
in  smallpox,  304 
tempo rosphenoidal,    in    scarlet 
fever,  322 
Acute  nephritis  in  scarlet  fever,  341 
Adenitis  m  scarlet  fever,  323 

suppurative,  in  measles,  361 
Albuminuria  during  smallpox,  312 
in  enteric  fever,  56,  118 
in  German  measles,  389 
in  measles,  361 
in  scarlet  fever,  319 
Alimentarv  canal  in  enteric  fever,  57, 

123,  209 
Alopecia  following  enteric  fever,  262 

smallpox,  307 
Amaurosis  following  enteric  fcA'er,  245 
Anaemia  following  enteric  fever,  112 
Angina,  Liidwig's,  in  scarlet  fever,  324 

in  scarlet  fever,  332 
Ankylosis  in  scarlet  fever,  325 
Anterior   poliomj-elitis    following   en- 
teric fever,  232 
Aphasia    during    and     after    enteric 
fever,  241,  242 
in  measles,  368 


Aphasia  in  scarlet  fever,  338 
Appendicitis  in  enteric  fever,  153,  269 

in  rncasleK,  358 
Appendix  in  enteric  fever,  153 
Arteriosclerosis  after  enteric  fever,  263 
Arteritis  following  enteric  fever,  205 
Arthritis  during  smallpox,  312 

in  chickenpox,  379 

following  enteric  fever,  263,  265 

in  German  measles,  389 

in  measles,  370 

in  scarlet  fever,  325 
Ascites  during  enteric  fever,  159 

in  scarlet  fe\er,  336 
Asthenia,    cerebral,  in  enteric  fever, 

295 
Ataxia  in  measles,  368 
Atrophy  in  measles,  368 

muscular,  in  measles,  368 


Bacilluria  in  enteric  fever,  119 
Bacteremia  in  enteric  fever,  113 
Bathing  in  enteric  fever,  27,  93 
Bed-sores  in  enteric  fever,  177 
Blebs  and  bulla^  in  scarlet  fever.  319 
Blood  cultures  in  enteric  fever,  113 

in  enteric  fever,  111 
Boils  in  chickenpox,  375 

in  enteric  fever,  177 

in  smallpox,  304 
Bones  in  chickenpox,  379 

complications    of,    in    smallpox, 
312 

in  measles,  370 

necrosis  of,  in  enteric  fever,  34, 
213 
in  scarlet  fever,  342 
Brain,  abscess  of.  in  measles.  365 
Bronchitis  during  smallpox,  304 

in  chickenpox,  379 

in  enteric  fever,  102.  172 

in  German  measles,  384 
Bronchopneumonia      in     chickenpox. 
379 

during  smallpox,  309 


394 


IXDEX 


Bronchopneumonia   in  enteric    fe\er, 
51,  54,  102 

in  CJeiinan  measles,  3S4 

in  measles,  3G2,  371 

in  scarlet  lever,  329 
Bulbar  paralysis  in  enteric  lever,  172 


CARrti'NCLES  in  enteric  fever,  177,  253 

in  smallpox,  305 
Cardiac  changes  in  scarlet  fever,  329 
Cartilage,  necrosis  of,  in  enteric  fever, 

95 
Casts,   urinarv,   in  enteric  fever,   56, 
116 
in  measles,  361 
in  smallpox,  313 
Catarrh,  abdominal,  or  enteric  fever, 
73 

nasopharyngeal,       in       German 
measles,  385 
"Catarrhal  re\er"  or  enteric  fever,  29 
Cellulitis  during  smallpox,  306 

orbital,  in  scarlet  fever,  343 
in  smallpox,  308 
Cerebral  asthenia  in  enteric  fever,  295 

congestion    in    German    measles, 
384 

paralysis  in  measles,  366 

sinus,  thrombosis  of,  in  smallpox, 
309, 315 

thrombosis  and  embolism,  170 
Chickenpox,  373 

abscesses  in,  375 

adult  life  in,  381 

arthritis  in,  379 

boils  in,  375 

bones  in,  379 

bronchitis  in,  379 

bronchopneumonia  in,  379 

encephalitis  in,  380 

endocarditis  in,  379 

erj-sipelas  in,  376 

fatal  cases  of,  376 

gangrene  of  skin  in,  374 

ha?matemesis  in,  376 

hemorrhagic  forms  of,  375 

" impetigo  Aaricellosa,"  374 

initial  symptoms  of,  373 

joints  in,  379 

kidneys  in,  380 

laryngitis  in,  378 

IjTnphadenitis  in,  377 

mela-na  in,  376 

meningitis  in,  380 

mucous  membranes  in,  378 

nephritis  in,  379,  380 

nervous  complications  in,  38 


Chickenpox,  neuritis  in,  380 
tvdema  in,  377 
otitis  media  in,  378 
paraplegia  in,  380 
jiarotitis  in,  377 
pemphigus  in,  375 
periostitis  in,  379 
pk'urisy  in,  380 
pya'uiia  in,  377 
retention  of  urine  in,  379 
scarring  in,  382 
second  attacks  of,  382 
skin  lesions  in,  374,  382 
synovitis  in,  379 
thyroiditis  in,  378 
varicella  or,  373 
Mtmiting  in.  373 
Ciiills  in  enteric  fever,  47,  80,  187 
Cholangitis  in  enteric  fever,  216 
Cholelithiasis  following  enteric  fever, 

222 
Chondritis  in  smallpox,  312 
Chorea  in  measles,  369 

in  scarlet  iexer,  329 
Choreiform     movements     in     scarlet 

iexer,  340 
Choroiditis  in  scarlet  fever,  343 

in  smallpox,  308 
Cicatricial    contraction    of    intestine 

after  enteric  fever,  211 
Circulation  in  enteric  fever,  108,  144, 

193 
Cirrhosis  of  liver  after  scarlet  fever, 

335 
Collapse  in  enteric  fever,  85 
Coma  in  smallpox,  315 
Congestion,      cerebral,     in      German 
measles,  384 
of   lungs,   hvpostatic,    in   enteric 
fever,  104" 
Conjuncti\'itis,  diphtheritic,  in  measles, 
360 
in  measles,  365 
in  scarlet  fever,  342 
in  smallpox,  312 
Constipation  in  enteric  fever,  132 

following  enteric  fever,  210 
Contraction,   cicatricial,   of  intestine, 

after  enteric  fever,  211 
Convulsions  in  enteric  fever,  66,  161, 
172 
in  German  measles,  391 
hysterical,  in  enteric  fever,  161 
in  measles,  366 
in  smallpox,  314,  315 
Corneal  ulcers  in  measles,  365 

in  smallpox,  307 
i  Coxitis  in  enteric  fever,  264 
'  Cutaneous  lesions  in  German  measles, 
I      387 


INDEX 


CycliU.s  (liiriiif!;  Htiiallpox,  30S 
CyHtitis  ill  cnUjnc  iovor,  122 
in  Hiii!iili)ox,  'M'.i 


Deaf  mutism  in  nica.sloK,  30.5 
in  Hcuiict  Icvor,  '.Vl'i 
Death,  sudden,  in  ontoric  lever,  194 
Delirium  in  enteric  lever,  2()0 
in  (i(;riiian  measles,  38i) 
in  smail|)o.\,  314 
Dementia  in  meashss,  'MY.) 
Dermal    complications    during  small- 
pox, 302 
Dermatitis     gangra^nosa     in     scarlet 

lever,  319 
Desquamation    during    enteric   fever, 

260 
Diagnosis,     differential,     in      enteric 

fever,  85,  206 
Diarrhoea  following  enteric  fever,  59, 
133,  210 
in  German  measles,  386 
in  measles,  357 
in  scarlet  fever,  334 
Digestive  system  in  smallpox,  310 

tract  in  measles,  354 
Diphtheria  in  measles,  351 
Diphtheritic  conjunctivitis  in  measles, 

366 
Dislocation  of  hip  in  enteric  fever,  264 
Disseminated     sclerosis    in    measles, 
367,  368 
in  smallpox,  316 
Duration,  short,  of  enteric  fever,  77 
Dyspnoea  in  measles,  351 


E 


Ear  complications  in  German  measles, 
388,  389 
in  smallpox,  309 
Ears  in  measles,  364 

in  scarlet  fever,  320,  323 
Eczema  in  measles,  358 
in  scarlet  fever,  347 
Embolism  in  enteric  fevei",  170,  195 
Emphysema,  subcutaneous,  in  enteric 
fever,  99 
in  measles,  359 
Empyema  in  enteric  fever,  107,  191 
of  frontal  sinus  in  measles,  366 
in  German  measles,  385 
in  measles,  360 
in  scarlet  feAer,  329 
in  smallpox,  310 
Encephalitis  in  chickenpox,  380 


lOtidocMrditis  in  chickenpox,  379 
'liiiing  i;nterio  lever,  11  J,  190 
in  G(;nnan  nieasles,  389 
in  rrieasleH,  304 
in  scarlet  l'e\-er,  330 
ill  Kiiiallpo.x,  31 1 

ulcerative,      resr^mhling      enteric 
fever,  270 
in  smallpox,  31 1 
Enlargement,   lymphatic,   in   German 

measles,  380 
Enteric  fe\er,  1 7 

"abdominal  catarrh,"  73 
abortive  forms  of,  42,  49,  77, 

79 
abscess  in,  177 

of  liver  in,  210,  219 
of  lung  in,  191 
afebrile  form  of,  73,  77 
aged  in  the,  80 
albuminuria  in,  56,  118 
alimentary  canal  in,  57,  123, 

209 
alopecia  following,  202 
amaurosis  following,  245 
aniemia  following,  112 
anterior  poliomyelitis  follow- 
ing, 234 
aphasia  during  and  after,  241 

242 
apyretical  form  of,  76 
appendicitis  during,  153,  269 
appendix  in,  153 
arteriosclerosis  after,  263 
arteritis  following,  205 
arthritis  foUo-o-ing,  263,  265 
ascites  during,  159 
bacilluria  in,  119 
bacteremia  in,  113 
bathing  in,  27,  93 
bed-sores  in,  177 
blood  in.  111 

cultures  in,  113 
boils  in,  176 
bronchitis  in,  102,  172 
bronchopneumonia     in,     51, 

54,  102 
bulbar  paralysis  in.  172 
carbuncles  iii,  177,  253 
casts  in  urine  during.  116 
"catarrhal  fever,"  29 
cerebral  asthenia  in.  295 
lesions  during.  236 
thrombosis   and   embol- 
ism in.  170 
children  with.  29 
chills  in.  47,  80,  1S7 
cholangitis.  216 
cholecystitis.  220 
cholelithiasis  following,  224 


39G 


IXDEX 


Enteric   fever,  cicatricial  contraction 
of  intestine  after,  211 
circulation  in,  108,  144,  193 
collapse  in.  So 
conditions    ^vhich    resemble, 

26G 
constipation  in,  133 

foUowinfi,  210 
convulsions  during,  00,   101, 

172 
coxitis  in,  264 
cystitis  in,  122 
delirium  during,  200 
desciuamation  during,  200 
diarrluea  following,  59,  133, 

210 
differential  diagnosis  in,  85, 

206 
diminution  of  morbidity  and 

mortality  of,  18 
dislocation  of  hip  in,  204 
duration  of,  270 
effect  of  improved  sanitation 
upon,  IS 
of  water  filtration  upon, 
21,  22,  23 
embolism  in,  170,  195 
empyema  in,  107,  191  • 
endocarditis  during,  111,  196 
epididymitis  during,  200 
epilepsy  during,  174 
epistaxis  during,  94 
eruptions    during,    00,    175, 

179 
eruptive  diseases  during,  180 
erysipelas  during,  253 
foetal  life  and,  35 
furunculosis  in,  177 
gall-bladder  infection  in,  45, 

151 
gangra'nous  stomatitis  in,  212 
gangrene  of  genitals  in,  212, 
215 
of  intestines  in,  211 
of  limbs  in,  202 
of  lung  in,  107,  191 
of  mouth  in,  212 
of  skin  in,  178,  212,  253 
gastric  ulcer  in,  126 
gastro-intestinal  tract  in,  58, 

212 
general  considerations  of,  17 
genito-urinary  tract  in,   56, 

115,205 
glandular   swelling   in,    123, 

225 
glossitis  in,  212 
ha-matemesis  in,  125 
ha'maturia  in,  50,  57,  116 
headache  during,  41, 162 


Enteric  fever,  heart  in,  108,  111,  196 
hemorrhage  from  stomach  in, 

120 
hemorrhagic     eruptions     in, 
179 
infarction,  106 
hemiplegia  in,  236 
hepatic  abscess  in,  210 
herpes  in,  178 
hypostatic    congestion    of 

lungs  in,  104 
hysterical  convulsions  in,  101 
innnunity  to,  278 
incul)ation  jx'riod  in,  39 
infarction  of  lungs  in,  100 
influenza  compared  with,  274 
insanity  during,  01,  101 
insomnia  during,  173 
intestinal  ulcers  in,  128 
intestines  in,  128 
jaimdice  in,  226 
joints  in,  203 
kidneys  in,  50,  116 
knee-jerks  in,  173 
knee-joints  in,  173 
lar^•ngeal  lesions  in,  55,  95, 

245 
"  larvngotyphoid,"  55 
leukocytosis  in,  112 
liver  in,  152,  210 
lobar  pneumonia  in,  51,  54, 

102,  105 
loss  of  hair  following,  262 
lumbar  puncture  in,  109,  270 
malaria  during,  61,  161,  244, 

282 
malignant  forms  of,  43 
measles  in,  181 
meningitis  during,   102 
mental  state  in,  01,  159,  244, 

282 
mesenteric  glands  in,  225 

suppuration  of,   in, 
225 
melancholia  in,  297 
miliary    tuberculosis  resem- 
bling, 270 
morbiditv  in,  18 

in  children,  29,  38 
in     pregnancv     and     in 
fa>tal  life,  35 
mortality  in,  18,  38 

and   morbiditv   in   later 
life,  38 
mountain  fe\cr,  274 
myelitis,  230 
myocarditis  in,  193,  204 
myositis  in,  247 
n(>crosis  of  bone  in,  34,  213 
of  cartilages  in,  95 


IND/'JX 


397 


Entoric  lover,  iicpliril.iH  in,  fjO,  1  I  (i 

norvouH  HyHUsin  in,   (il,    159, 

227 
ncuritiH  in,   171,  229 
neuroHCH  in,  250 
noiTiii  in,  212 
aHlotrui  of  iliorux  jind  ;il)(io- 

incn  ui'ter,  2(12 
ocHopliugoul   IcsioriH   in,    123, 

214 
orcliifis  (luriiif:;,  205 
osteitis  roUowing,  2()r) 
ostcoinyolitis  n!K(Mnl)linf^,  269 
pain  in  iibdoinen  in,  llif) 
paralysis  duriiif!;,  171,  245 
parotitis  during,  212 
perforation  in  children,  33, 138 

during,  140 

following,  210 

of   the   gall-bladder   in, 
152 
pericarditis  following,  196 
perichondritis  during,  97,  99 
periostitis  after,  265 
"  pharyngo typhoid,"  55 
pharynx  in,  57,  124 
phlebitis  in,  201 
phlegmasia  alba  dolens,  201 
pleurisy  in,  55,  106 
"  pleurotyphoid,"  55 
pneumonia  in,  51,  54,  102 
pneumothorax,  108 
"pneumotyphoid,"  51,  105 
poliomyelitis  during,  234 
polyuria  in,  123 
pregnancy  in,  35 
prognosis  in,  89 

of  mental  complications, 
298 
prodromal  rashes  in,  66 
pseudodementia  in,  295 
pseudoparal.ysis  in,  295 
puerperal  septicaemia  resem- 
bling, 274 
pulmonary  complications  in, 
54,  102,  104 

oedema  in,  104 
pulse  in,  108 

pus  containing  specific  organ- 
isms in,  177 

in  urine  during,  118 
pyjemia  in,  269 
pylephlebitis  in,  219 
pj'onephrosis,  122 
pyuria  in,  119 
rash  of,  66,  175 
recent  epidemics  of,  28 
recrudescences  of,  182 
recurrences  in,  279 
relapses  in,  182,  186 


JMitcric    fever,   respiratory    cf)rri[>licu- 
tioiiH  in,  51,  94,  191 

reHtleHsnoHH  in,  173 
retention  of  urine  in,  57 
rigors  in,  47,  SO,  187 
sanitutirm  in,  18 
scarlet  fever  in,  180,  275 
second  attacks  of,  279 
septicaemia  resembling,  269, 

274 
short  duration,  77 

incubation,  39 
skin  in,  66,  174,  178,  253,  261 
spine  in,  248 
spleen  in,  114,  227 
splenotyjilioid,  1 15 
spondylosis  in,  250 
stomach  in,  125 
stomatitis  in,  212 
strabismus  in,  212 
stuporous  insanity  in,  294 
subcutaneous  emphysema  in, 

99 
sudamina  in,  177 
sudden  death  in,  194 
sudoral  typlioid  fever,  48 
suppuration   of   the   thyroid 

gland,  262 
suppurati\e    pylephlebitis, 

219 
sweating  in,  48,  259 
synoyitis  in,  177,  265 
temperature  during,  44,   68, 
205 

yariations  from  usual  in 
onset,  44 
testicle  in,  205 
tetany  in,  251 
third  attacks  of,  280 
thrombosis  in,  170,  195,  203 
thyroid  gland  in,  262 
tonsils  in,  57 
tremors  in,  245 
tuberculosis  during,  104,  191, 
270 

miliary,  resembling,  270, 
271" 
tuberculous     peritonitis     re- 
sembling, 271 
typhoid  cholangitis  in,  218 

coxitis,  264 

feyer,  17 

spine,  248 
"typhus  leyissimus."  77 
ulceratiye     endocarditis     re- 
sembling, 270 

stomatitis.  212 
urethritis  during,  206 
urinary-  casts  in,  56.  116 
yarieties  of  onset  in.  41 


398 


INDEX 


Enteric  fever,  vascular  lesions  in,  109 
veins  in,  201 
vomiting  in,  59,  125 
water  supply  as  cause  of,  19 
without     intestinal     lesions, 
129,  169 
Enteritis  in  measles,  357 
Epidemic  roseola  or  Gennan  measles, 

3S4 
Epididymitis  in  enteric  fever,  206 
Epilepsy  during  enteric  fever,  174 

in  scarlet  ievev,  340 
Epistaxis  during  enteric  fever,  94 

in  smallpox,  305 
Eruptions   during   enteric   fever,    66, 
175,  179 
hemorrhagic,  in  enteric  fever,  179 
in  measles,  349,  358,  359 
septic,  in  smallpox,  303 
in  smallpox,  302 
EruptiAC  diseases  during  enteric  fever, 

179 
Erysipelas  in  chickenpox,  376 
in  enteric  fever,  253 
in  German  measles,  388 
Eve  complications  in  German  measles, 
388,389 
in  smallpox,  307 
in  measles,  365 


Facial  paralysis  in  scarlet  fever,  322 

in  smallpox,  309 
"Fever, catarrhal,"  or  enteric  fever, 29 
enteric,  17.     5ee  Enteric  fever, 
mountain,  or  enteric  fever,  274 
scarlet,  in  enteric  fever,  180,  275 
tvphoid,  sudoral,  in  enteric  fever, 
■  48 
Filtration   of   water,  effect   of,  upon 

enteric  fever,  21,  22,  23 
Foetal  life  and  enteric  fever,  35 
Furunculosis  in  enteric  fever,  177 
in  scarlet  fever,  347 
in  smallpox,  304 


G 


Gall-bladder,  infection  of,  in  enteric 

fever,  45,  152 
Gangrene  of  genitals  in  enteric  fever, 
107,212,215 
in  measles,  3G0,  363 
in  smallpox,  306 
of  intestines  in  enteric  fever,  211 
of  limbs  in  enteric  fever,  202 
of  lung  in  enteric  fever,  107,  191 


Gangrene  of  lung  in  measles,  354 
of  mouth  in  enteric  fever,  212 
in  scarlet  fever,  319 
of  skin  in  chickenpox,  374 

in  enteric  fever,  178,  212,  253 
in  measles,  360 
in  scarlet  fever,  319 
in  smallpox,  306 
Gangrenous  stomatits  in  enteric 
fever,  212 
in  measles,  354 
in  smallpox,  310 
Gastric  ulcer  in  enteric  fever,  126 
Gastritis  in  scarlet  fcAcr,  324 
Gastro-intestinal  tract  in  enteric  fever, 
58,  212 
in  German  measles,  386 
Genitals,  gangrene  of,  in  enteric  fever, 
212,  215 
in  measles,  360,  363 
in  smallpox,  306 
Genito-urinary  complications  in 
measles,  361 
in  smallpox,  312 
tract  in  enteric  fever,  56,  115,  205 
Gemian  measles,   382.     See  Measles, 

German. 
Glands,  lymphatic,  in  measles,  361,372 
mesenteric,  in  enteric  fever,  225 
suppuration  of,  in  enteric 
fever,  225 
thyroid,  in  enteric  fever,  262 
in  German  measles,  385 
in  smallpox,  311 
Glandular  abscesses  in  measles,  361 

swelling  in  enteric  fever,  124,  225 
Glossitis  in  enteric  fever,  212 

in  smallpox,  310 
Glottis,  oedema  of,  in  measles,  351 
in  smallpox,  309 


H.EMATEMESis  in  cntcric  fever,  126 
Ha-maturia  in  enteric  fever,  56,  57,  116 

in  measles,  362 
Haemoptysis  in  smallpox,  309 
Hair,  loss  of,  following  enteric  fever, 
262 
following  smallpox,  307 
Headache  during  enteric  fever,  41,  162 
Heart,  acute  dilatation  of,  in  small 
pox,  309 

in  enteric  fever,  lOS,  111,  196 

in  German  measles,  389 

in  measles,  363 

in  .scarlet  fever,  329 

in  smallpox,  311 
Hemiplegia  in  enteric  fever,  236 


INDEX 


y/.i'.} 


Hemi|)li^fi;i.'i,  in  hcuxU-A,  fever,  '.',2'.> 

ill  ,siii!i.ll|)o,\,  '.ilT) 
Hem()i'rli;i,f;;e  (luring!;  seiulet  fever,  321 

reliiiiil,  in  sin.'illpox,  '.iOX 

from  siroiii.'icli  in  eiii.eric  fever,  126 
llemorrliiif^ic     ei  U|)l,i()iiH     in     enteric 
fever,  17.S 

form  of  ni(!;isle,s,  lidO 

infarction  in  eiiUsric  fever,  lOG 

IcHioiiH  in  (J(!rnuin  nieaHles,  '.iHH 
Hepatic  abscess  in  enteric  fever,  216 

lesions  in  enteric  fever,  216 
Herpes  in  enteric  fever,  178 

in  measles,  358 

in  scarlet  fever,  .318 
Hip,  dislocation  of,  in  enteric  fever,  264 
Hydrocele  in  smallpox,  313 
Hydrothorax  in  measles,  353 

in  smallpox,  310 
Hypostatic    congesiton    of    lungs    in 

enteric  fever,  104 
Hysterical  convulsions  in  enteric  fever, 
161 


Immunity  to  enteric  fever,  278 
Impetigo  in  measles,  358 

in  smallpox,  304 

varicellosa  in  chickenpox,  374 
Incubation  period  in  enteric  period,  39 

short,  of  enteric  fever,  39 
Infarction,    hemorrhagic,    in    enteric 
fever,  106 

of  lungs  in  enteric  fever,  106 
Influenza  compared  with  enteric  fever, 

106 
Insanity  during  enteric  fever,  61,  161 
scarlet  fever,  337 

following  smallpox,  315 

stuporous,  in  enteric  fever,  294 
Insomnia  during  enteric  fever,  173 
Intestinal  lesions,  enteric  fever  with- 
out, 129,  169 

ulcers  in  enteric  fever,  128 
Intestine,    cicatricial    contraction    of, 
after  enteric  fever,  211 

in  enteric  fever,  128 

gangrene  of,  in  enteric  fever,  211 

in  measles,  358 
Intracranial  abscess  in  measles,  365 
Iritis  following  smallpox,  308 


Jaundice  in  enteric  fever.  226 
in  Gennan  measles,  388 
in  scarlet  fe^•er,  336 


Joints  in  eliifkcn|)0\,  379 

complications    of,     in     -inall)>ox, 

312 
in  enteric  fever,  263 
in  measles,  370 


Kkhatjti.s  in  (icnnuri  measles,  'JS8 

in  scarlet  fever,  343 

in  smallpox,  308 
Kidnciv,  abscess  of,  in  smallpox,  312 

in  chickenpox,  380 

in  enteric  lever,  56,  116 

in  Gennan  measles,  389 

in  measles,  362 

in  scarlet  fever,  326 

in  smallpox,  313 
Knee-jerks  in  enteric  fever,  1 73 
Knee-joints  in  enteric  fever,  173 


Laryngeal  lesions  in  enteric  fever,  55, 

95,  245 
Laryngitis  in  chickenpox,  378 
in  measles,  350 
membranous,  in  measles,  350 
in  smallpox,  309 
ulcerative,  in  measles,  350 
"  Larvngotyphoid"  in  enteric  fever,  55 
Lar3-nx,  necrosis  of,  in  measles,  351 
ulceration  of,  in  smallpox,  309 
Leukocytosis  in  enteric  fever,  112 
Limbs,  gangrene  of,  in  enteric  fever, 

202 
Liver,  abscess  of,  in  enteric  fever,  216, 
219 
in  smallpox,  312 
cirrhosis  of,   after  scarlet   fever, 

335 
in  enteric  fever,  152,  216 
in  scarlet  fever,  335 
Lobar  pneumonia  in  enteric  fever,  51, 
54,  102,  105 
in  measles,  352 
in  scarlet  fever,  32S 
in  smallpox,  309 
Ludwig's  angina  in  scarlet  fever,  324 
Lumbar  puncture  in  enteric  fever,  169, 

270 
Lungs,  abscess  of,  in  enteric  fever,  191 
gangrene  of,  in  enteric  fever.  107, 
191 
in  measles,  354 
hypostatic   congestion  of,  in  en- 
teric fever,  104 
infarction  of,  in  enteric  fever,  106 


400 


INDEX 


Lungs,     tuberculosis     of,     following 

measles,  ,'^53,  371 
Lj  mphailenitis  in  chickenpox,  377 
Lymphatic    enlargement    in    Ciemian 
measles,  380 

glands  in  measles,  301,  372 


M 


Malaria    during    enteric    fe\er,    61, 

101,  244,  282 
Malignant  forms  of  enteric  fe\-er,  43 
Mania  in  scarlet  {e\er,  337,  347 

during  smallpox,  315 
Mastoid  suppuration  in  measles,  305 

in  snaallpox,  309 
Mastoiditis  in  scarlet  fever,  321 
Measles,  348 

albuminuria  in,  301 

aphasia  in,  308 

appendicitis  in,  358 

artnritis  in,  370 

ataxia  in,  308 

atrophy  in,  308 

bones  in,  370 

brain  abscess  in,  305 

Ijronchopneumonia  in,  302,  371 

casts,  urinary  in,  301 

cerebral  paralj-sis  in,  360 

chorea  in,  309 

complications  of,  348,  350 

conjunctivitis  in,  305 

convulsions  in,  360 

corneal  ulcers  in,  305 

deaf  mutism  in,  305 

diarrha?a  in,  357 

digestive  tract  in,  354 

dementia  in,  309 

diphtheria  in,  351 

diphtheritic  conjunctivitis  in,  366 

disseminated  sclerosis  in,  367,  368 

dyspnoea  in,  351 

ears  in,  304 

eczema  in,  358 

emphvsema  subcutaneous  durine, 
359 

empyema  in,  352 

of  frontal  sinus  in,  366 

endocarditis  in,  364 

in  enteric  fever,  181 

enteritis  in,  357 

eruptions  in,  349,  358,  359 

eyes  in,  365 

gangrene  of,  genitals  in,  360,  363 
of  lung  in,  354 
of  skin  in,  360 

gangrenous  stomatitis  in,  354 

geni to-urinary   complications   in, 
361 


Measles,  Cierman,  ;W4 

age  of  patients  in,  391 

albununuria  in,  389 

arthritis  in,  389 

bronchitis  in,  384 

bronchopneumonia  in,  384 

cerebral  congestion  in,  382 

complications  in,  384 

con\  ulsions  in,  391 

cutaneous  lesions  in,  387 

deaths  in,  39!) 

delirium  in,  ;iS9 

tliarrluea  in,  386 

ear  comjilications  in,  388,  389 

empyema  in,  385 

endocarilitis  in,  389 

epidemic  roseola  or,  382 

erysipelas  in,  388 

eve    complications    in,    388, 
'  389 

gastro-intestinal  tract  in,  386 

heart  in,  389 

hemorrhagic  lesions  in,  388 

jaundice  in,  388 

keratitis  in,  388 

kidneys  in,  389 

Ivmphatic    enlargement    in, 
'  380 

mortality  in,  390 

nasopharyngeal  catarrh,  385 

nephritis  in,  389 

oedema  in,  388 

otitis  media  in,  388 

parotitis  in,  385 

pericarditis  in,  389 

pleurisy  in,  385 

rashes  in,  387 

relapse  in,  380 

rubella  or,  384 

skin  in,  388 

stomatitis  in,  385 

svnovitis  in,  389 

throat  comjjlications  in,  385 

thyroid  gland  in,  385 

Aomiting  in,  380 
glands  in,  30l 

glandular  abscesses  following,  301 
ha?maturia  in,  362 
heart  in,  363 
hemorrhagic  form  of,  360 
herpes  in,  358 
hydrothorax  in,  353 
impetigo  in,  358 
intestines  in,  35S 
intracranial  abscess  in,  305 
joints  in,  370 
kidneys  in,  302 
laryngitis  in,  350 
lobar  pneumonia  in,  352 
lymphatic  glands  in,  301,  372  7 


INDEX 


401 


Measles,  nuislioid  sii|)pur;i,Lio[i  in,  l}(;5 

mcnibnuioiiH  iiiryii^ilis  in,  I'.fiO 

inoiiiiif^il.is  in,  Hdf),  /ifiS,  '.',1\ 

mon(,iil  (ii.shiii),'i,nc;(;s  in,  :i(i!) 

miliary  vesicios  in,  '.'yh\) 

mortality  of,  .'fl8 

muscular  atrophy  in,  'M\H 

myocarditis  in,  'MV.\ 

necrosis  (jj'  larynx,  Ilfjl 

nephritis  in,  '.M\2 

nervous  system,  3(j() 

neuritis  in,  ^(i!) 

noma  in,  '^M 

oedema  of  the  j^lottis  in,  351 

osteitis  in,  370 

otitis  media  in,  304,  371 

paraplegia  in,  307 

pericarditis  in,  36-1 

phlebitis  in,  304 

pleurisy  in,  353 

polio-encephalitis  in,  368 

paralysis  in,  3(i(j 

paraplegia  in,  3(37 

parotitis  in,  357 

pulmonary  complications  in,  351, 
371 
tuberculosis  following,  353 

pregnancy  in,  370 

prodromal  rashes  in,  349 

psoriasis  in,  359 

purpura  in,  359 

rashes  in,  349,  358,  359 

relapse  in,  370 

respiratory  tract  in,  350 

retropharyngeal  abscess  in,  357 

second  attaclvs  of,  371 

sequels  of,  371 

skin  complications,  358 

spinal  meningitis  in,  369 
paralysis  in,  367 

statistics  of,  348 

stomach  in,  354 

stomatitis  in,  354 

subcutaneous  emphysema  in,  359 

suppurative  adenitis  in,  361 

"sweating  measles,"  349 

third  attacks  of,  371 

thrombosis  in,  365 

tonsils  in,  356 

tuberculosis  of  the  lungs  follow- 
ing, 353,  371 
of  the  skin  in,  358 

ulcerative  laryngitis  in,  350 
stomatitis  in,  354 

urethritis  during,  362 

urticaria  in,  35S 

vulva,  ulcers  of,  in,  363 

vuhitis  during,  363 
MehT?na  in  chickenpox,  376 
Melancholia  in  enteric  fever,  297 

26 


Mobuicljolia  in  scarlet  fever,  337,  .'347 

during  smallpox,  315 
Membru/ies,   mucous,   in    chickenpox, 

378 
Mem'ngitis  in  chickenpox,  380 
in  enteric  U-ycr,  I(i2 
in  measles,  365,  368,  371 
in  scarlet  fever,  322,  337 
spinal,   in   measles,   369 
Mental  affections  after  smallpox,  315 
complications,     prognosis    of,    in 

enteric  fever,  298 
disturbances  in  measles,  369 
state   in   enteric   fever,    61,    159, 
244,  282 
Mesenteric  glanfis  in  enteric  fe\er,  225 
suppuration    of,    in    enteric 
fever,  225 
Miliary  tuberculosis  resemliling  enteric 
fever,  270,  271 
vesicles  in  measles,  359 
Miscarriage  fluring  smallpox,  314 
Morbidity  in  children  in  enteric  fe\-er, 
29,  38 
in  enteric  fever,  18 
and  mortality,  diminution  of,  of 

enteric  fever,  18 
in   pregnancy   and   foetal  life  in 
enteric  fever,  35 
Mortality  in  enteric  fever,  18,  38 
in  German  measles,  390 
and    morbidity    in    later    life    in 
enteric  fever,  38 
Mountain  fever  or  enteric  fe-\er,  274 
Mouth,  gangrene  of,  in  enteric  fever, 

212 
Movements,     choreiform,    in     scarlet 

fever,   340 
Mucous    membranes    in    chickenpox, 

378 
Muscular  atrophy  in  measles,  368 
Myelitis  in  enteric  fever,  236 

in  smallpox,  316 
Mj'ocarditis  during  smallpox,  311 
in  enteric  fever,  193,  204 
in  measles,  363 
in  scarlet  fe-ver,  328 
Myositis  in  enteric  fe^•er,  247 
in  scarlet  fever,  342 


N 


Nails,    loss   of,    following;    smallpox, 

307 
Nasopharyngeal   catarrh    in    Gennan 

measles,  385 
Necrosis  of  bone  in  enteric  fever.  34, 
213 
in  scarlet  fever,  342 


402 


INDEX 


Necrosis  ol"  cartilage  in  enteric  fever,  95 

of  larynx  in  measles,  8"il 
Nephritis,  acute,  in  scarlet  fever,  341 

in  chickenpox.  379,  3S() 

in  enteric  fever,  oii,  115 

in  German  measles,  389 

in  measles,  302 

postscarlatinal,  32S 

in  scarlet  fever,  32G 

in  smallpox,  312 
Nervous  svstem  in  enteric  fever,  Gl, 
■  159,  22S 
in  measles,  3(36 
in  scarlet  fever,  337 
in  smallpox,  314 
Neuritis  in  chickenpox,  3S0 

in  enteric  fe^er,  174,  229 

in  measles,  369 

optic,  in  scarlet  fever,  344 

in  scarlet  fever,  339 

in  smallpox,  316 
Neuroses  in  enteric  fever,  250 
Noma  in  enteric  fever,  212 

in  measles,  354 

in  scarlet  fever,  333 

in  smallpox,  310 


Ocular  lesions  in  scarlet  fever,  342 

in  smallpox,  307 
CEdema  in  chickenpox,  377 

in  Geniian  measles,  388 

of  glottis  in  measles,  351 
in  smallpox,  309 

of    thorax    and    abdomen    after 
enteric  fever,  262 
OEsophageal  lesions  in  enteric  fever, 

124,  214 
Onset,  varieties  of,  in  enteric  fever, 

41 
Onychia  in  scarlet  fever,  341 
Optic  neuritis  in  scarlet  fever,  344 
Orchitis  in  enteric  fever,  205 

in  scarlet  fever,  341 

in  smallpox,  313 
Osteitis  following  enteric  fever,  265 

in  measles,  370 

in  scarlet  fever,  342 

in  smallpox,  312 
Osteomvelitis  resembling  enteric  fever, 
269 

in  scarlet  fever,  342 

in  smallpox,  312 
Otitis  media,  in  chickenpox,  378 

in  German  measles,  388 

in  measles,  364,  371 

in  scarlet  fever,  320 

in  smallpox,  308 


Pain  in  alulonien  in  enteric  fever,  136 
Palate,  ulceration  of,  in  smallpox,  310 
Paralysis,   acute   ascentling,   in   small 
pox,   316 

bulbar,  in  enteric  fever,  172 

cerebral,  in  measles,  366 

during  enteric  fever,  174,  245 
smallpox,  315,  316 

facial,  in  scarlet  fever,  322 
in  smallpox,  309 

in  measles,  366 

spinal,  in  measles,  367 
Paraplegia  in  chickenpox,  380 

following  smallpox,  316 

in  measles,  367 

in  scarlet  fe\er,  339 
Parotitis  during  smallpox,  310 

in  chickeniiox,  375 

in  enteric  fever,  212 

in  German  measles,  388 

in  measles,  357 

in  scarlet  fever,  341 
Pemphigus  in  chickenpox,  375 
Perforation  in  children  during  enteric 
fever,  33,  139 

during  enteric  fe\er,  140 

foUoAving  enteric  fe\er,  210 

of  gall-bladder  in  enteric  fever, 
152 
Pericarditis  during  smallpox,  331 

following  enteric  fever,  389 

in  German  measles,  389 

in  measles,  364 

in  scarlet  fever,  331 
Perichondritis    during    enteric    fever, 
97,  99 

in  scarlet  fever,  328 
Periostitis  in  chickenpox,  379 

after  enteric  fever,  265 

in  scarlet  fever,  342 
Peritonitis  during  .smallpox,  312 

in  scarlet  fever,  336 

tuberculous,    resembling    enteric 
fever,  271 
Pharyngitis  in  smallpox,  310 
"  Pharyngotyphoid"  in  enteric  fever, 

55 
Pharj'nx  in  enteric  fever,  57,  124 

in  scarlet  fever,  325,  333 
Phimosis  in  smallpox,  312 
Phlebitis  in  enteric  fever,  201 

in  measles,  364 

in  scarlet  fever,  332 

in  smallpox,  311 
Phlegmasia    alba    dolens    in    enteric 

fever,  201 
Pleuri.sy  in  chickenpox,  380 

in  enteric  fever,  55,  106 


INDEX 


403 


PleuriHy  in  (Icnniin  iiio;i„sIoh,  .'J8.5 
in  riK!iisl(!K,  '.\^h\ 
in  HCiU'lct  lever,  ."52!) 
in  sni.'illpox-,  ;{1() 
"  Pleurotypiioid"  in  cnlciie  IcA'er,  .55 
Pneunioniu  in  enteric  lever,  ."jl,  .54,  102 
lobiir,    in    enteric    fever,    51,    .54, 
102,   105 
in  ni('iisl(!s,  ;{52 
in  .scai-let  lever,  .'52S 
in  .snijillpox,  .SOO 
in  scarlet  lexer,  ;i29 
in  .smallpox,  310 
Pneumotlun-ax  in  enteric  lever,  108 
"Pneumotyphoid"  in  enteric  lever,  51, 

105 
Polio-encephaliti.s  in  measles,  .368 
Poliomyelitis,  anterior,   following  en- 
teric lever,  234 
durinji;  enteric  lever,  234 
Polyuria  in  enteric  lever,  123 
Postpharyngeal  abscess  in  smallpox, 

311 
Postscarlatinal  nephritis,  328 
Pregnancy  complicating  smallpox,  313 
in  enteric  fever,  35 
in  measles,  370 
Pseudoclementia  in  enteric  fe\-er,  203 
Pseudoparalysis  in  enteric  fever,  295 
Psoriasis  in  measles,  359 
Puerperal  septica?mia  resembling  en- 
teric fever,  274 
Pulmonary    complications   in    enteric 
'  fever,  54,   102,   104 
in  measles,  351,  371 
oedema  in  enteric  fe\-er,  104 
tuberculosis  following  measles,  353 
Pulse  in  enteric  fever,  108 
Puncture,  lumbar,  in  enteric  fever,  169 

270 
Purpura  ha-morrhagica,  340 

in  measles,  359 
Pus  containing  specific  organisms  in 
enteric  fever,  177 
in  vu'ine  during  enteric  fever,  119 
Pyaemia  in  chickenpox,  377 

in  enteric  fever,  269 
Pylephlebitis  in  enteric  fever,  219 

suppurative,  in  enteric  fever,  219 
Pyoneplirosis  in  enteric  fever,  122 
Pvuria  in  enteric  fever,  119 


Rash  of  enteric  fever,  66,  175 
in  German  measles,  387 
initial,  in  smallpox,  302 
in  measles,  349,  358,  359 
prodromal,  in  enteric  fever,  66 


liasl),  prodromal,  in  inc'ihles,  .319 
in  HC'irlci   fever,  3IS 
in  .smallpox,  -302 
Respiratory  cornplication.s  in  enteric 
fever,  51,  94,  191 
in  Htnallpox,  •3f)9 
system  in  scarh-t  friver,  ,328 
tract  in  rneaHlrj.s,  .3.50 
Piestle.ssnesH  in  entf;ric  fever,  173 
Retention  of  urine  in  smallpox,  312 

in  enteric  fever,  57 
Retinitis  in  smalljirix,  308 
Hct  nij)li;irvngeal  abscess   in   measles, 
'  357 
in  .scarlet  fe\'er,  333 
Rhinorrhrra  in  scarlet  fevf;r,  319 
Rigors  in  enteric  fever,  47,  80,  187 
Roseola,  epidemic,  or  German  measles, 

384 
Rubella  or  German  measles,  384 


S 


Sanitation,    effect   of,    upon   enteric 
fever,   18 
in  enteric  fever,  18 

Scarlatinal     rheumatism     in     scarlet 
fever,  324 
syno^•itis  in  scarlet  fever,  324 

Scarlet  fever,  317 

ab.scesses  in,  341 

acute  nephritis  in,  328 

adenitis  in,  323 

albuminuria  in,  319 

alimentary  canal  in,  332 

angina  in,  3.32 

ankj-losis  in,  .325 

aphasia  in,  338 

arthritis  in,  .325 

ascites,  336 

blebs  and  bulhe  in.  319 

bronchopneumonia  in.  -329 

cardiac  changes  in.  329 

chorea  in.  .329 

choreifonn     movements     in, 

340 
choroiditis  in,  .343 
cirrhosis   of   the   liver   after, 

335 
complications  of.  319 
conjunctivitis  in.  342 
deaf  mutism  after,  323 
dennatitis  gangra?uosa  in.  319 
diarrhoea  in,  334 
ears  in,  320.  323 
eczema  in,  347 
empyema  in,  329 
endocarditis  in,  330 
in  enteric  fever.  ISO.  275 


404 


IXDEX 


Scarlet  lever,  epilepsy  in.  340 

facial  paralysis  in,  322 
I'urunculosis  in,  347 
gangrene  in.  319 

of  skin  in,  319 
gastritis  in,  324 
heart  in,  329 
hemiplegia  in,  33S 
hemorrhage  during,  321 
herpes  in,  31S 
insanity  tiuring,  337 
jaimdice  in.  33(j 
keratitis  in,  343 
kidneys  in,  32(5 
liver  in,  335 
lobar  pneumonia  in,  329 
Ludwig's  angina  in,  324 
mania  in,  337.  347 
mastoiditis  in,  321 
melancholia  in,  337,  347 
meningitis  in.  322,  337 
mortality  in,  317.  322,  337 
myocarditis  in,  330 
myositis  in,  342 
necrosis  of  bone  in,  342 
nephritis  in,  326 
nervous  .system  in,  337 
neuritis  in.  339 
noma  in,  333 
ocular  lesions  in,  342 
onychia  in.  341 
optic  neuritis  in,  344 
orbital  cellulitis  in,  343 
orcliitis  in,  341 
osteitis  in,  342 
osteomj-elitis,   342 
otitis  media  in,  320 
paraplegia  in,  339 
parotitis  in,  341 
pericarditis  in,  331 
perichondritis,  328 
periostitis,  342 
peritonitis  in,  336 
phar\-nx  in,  325,  333 
phlebitis  in,  332 
pleurisy  in,  329 
pneumonia  in,  329 
postscarlatinal  nephritis,  328 
premonitory-  rashes  in,  318 
purpura  ha>morrhagica,  340 
relapse  in,  345 
respiratory  system  in,  328 
retropharyngeal   abscess   in, 

333 
rhinorrhor'a  in,  319 
scarlatinal    rheumatism    in, 
324 
synovitis  in,  324 
second  attacks  of,  346 
sequels  of,  346 


Scarlet    fever,    sinus    thrombosis  in, 
322 

skin  lesions  in.  340 
stomatitis  in,  332 
surgical  scarlet  fe\er  in,  344 
temporosphenoitlal      abscess 

in,  322 
tetany  in,  340 
tonsillitis  in,  332 
unemia  in,  327 
urticaria  in,  31S 
vomiting  in,  334 
Scarring  in  chickenpox,  382 

in  smallpox,  306 
Sclerosis,    disseminated,    in    measles, 
367,  368 
in  smallpox,  316 
Septiccpmia,  puerperal,  resembling  en- 
teric fe\er,  274 
resembling  enteric  fever,  269,  274 
Sinus  thrombosis  in  scarlet  fever,  322 
Skin  com])lications  in  measles,  358 
in  enteric  fe\er,  {j6,  174,  178,  253, 

261 
gangrene  of,  in  chickenpox,  374 
in    enteric    fever,    178,   212, 

253 
in  measles,  360 
in  smalljiox,  30<) 
in  German  measles,  388 
lesions    of,    in    chickenpox,    374, 
382 
in  scarlet  fe\-er,  340 
tuberculosis  of,  in  measles,  358 
Smallpox,  301 

abdominal  complications  during, 

312 
abscess  in,  304 

of  kidney  in,  312 
of  Uver in,  312 
acute  ascending  paralysis  in,  316 
dilatation    of    the   heart   in, 
311 
albuminuria  during,  312 
alopecia  following,  307 
arthritis  during,  312 
boils  in,  304 

bone  complications  in,  312 
bronchitis  during,  304 
bronchopneumonia  during,  309 
carbuncles,   305 
casts  urinary  in,  313 
causes  of  outbreaks  of,  301 
cellulitis  during,  306- 
chondritis  during,  312 
choroiditis  in,  308 
coma  in,  315 

conjunctivitis  during,  312 
convulsions  during,  314,  315 
corneal  ulceration  in,  307 


INDEX 


405 


Small |)()x,  cycliii.s  diiriiig,  ,308 
0VH(il.iH  'luriiif^,  '.'>\'.'> 
(l'(\'iJ,h-r!iU;  in,  :'M2 
clcliriiiiti  (lun'iif^,  .'■{!  1 
(loriiial  coriiplioations  during,  .'i02 
digestive  HyHtcm  in,  .'J  10 
di.s.s(!tninatod  sclerosis  in,  310 
ear  O(jni[)lications  in,  '.M)\) 
eiTipyetna  in,  1510 
endocarditis  in,  lUl 
cpistaxis  in,  iiO.") 
eruptions  in,  'MY2 
eye  complications  in,  307 
racial  paralysis  in,  309 
i'urunculosis  in,  304 
gangrene  of  genitals  in,  30G 

ol'  skin  in,  30(i 
gangrenous  stomatitis  in,  310 
genito-urinarv    complications  in, 

312 
glossitis  in,  310 
haemoptysis  in,  309 
heart  in,  311 
hemiplegia  in,  315 
hemoptysis  in,  309 
hydrocele  in,  313 
hydrothorax  in,  310 
impetigo  in,  304 
incidence  of,  301 
initial  rashes  of,  302 
insanity  following,  315 
iritis  in,  308 

joint  compHcations  in,  312 
keratitis  in,  308 
kidneys  in,  313 
laryngitis  in,  309 
lobar  pneumonia  in,  309 
loss  of  hair  following,  307 
of  nails  following,  307 
mania  during,  315 
mastoid  suppuration  in,  309 
melancholia  during,  315 
mental  affections  after,  315 
miscarriage  during,  314 
myelitis  in,  316 
myocarditis  in,  311 
nephritis  in,  312 
neuritis  in,  316 
nervous  system  in,  314 
noma  in,  310 
ocular  lesions  in,  307 
oedema  of  the  glottis  in,  309 
orbital  cellulitis  in,  308 
orchitis  in,  313 
osteitis  in,  312 
osteomyelitis  in,  312 
otitis  media  in,  308 
paralysis  during,  315,  316 
paraplegia  following,  316 
parotitis  during,  310 


Smallpox,  p<.Tif;!ir'lilis  ill,  31  I 

pcritonids  during,  312 

pharyngitis  in,  310 

pliiiiiosis  in,  312 

phlebitis  in,  31 1 

pleurisy  in,  310 

jineuinonia  in,  309 

postph/iryngeal  abscess  in,  311 

jiregnancy  implicating,  313 

prodromal  rashes  in,  302 

j'ashes  in,  302 

respiratory  complications  in,  309 

retention  of  urine  in,  312 

retinal  liemorrliage  in,  308 

retinitis  in,  308 

scarring  in,  306 

septic  eruptions  in,  303 

stomatitis  in,  310 

susceptibility  to,  301 

thrombosis    of    cerebral    sinuses 
in,  309,  315 

thyroid  gland  in,  311 

tongue  in,  310 

ulceration  of  larynx  in,  309 
of  palate  in,  310 

ulcerative  endocarditis  in,  311 
stomatitis  in,  310 

variola,  301 
Spinal  meningitis  in  measles,  369 

parah'sis  in  measles,  367 
Spine  in  enteric  fever,  248 
Spleen  in  enteric  fever  114,  227 
"  Splenotyphoid"  in  enteric  fever,  115 
Spondylosis  in  enteric  fever,  250 
Stomach  in  enteric  fever,  125 

hemorrhage  from,  in  enteric  fever, 
126 

in  measles,  354 
Stomatitis  in  enteric  fever,  212 

in  German  measles,  385 

in  measles,  354 

in  scarlet  fever,  332 

in  smallpox,  310 

gangrenous,  in  enteric  fever,  212 
in  measles,  354 
in  smallpox,  310 

ulce^ati^■e,  in  enteric  fever,  212 
in  measles,  350 
in  smallpox,  310 
Strabismus  in  enteric  fever,  212 
Stuporous  insanitv  in  enteric   fever, 

294 
Subcutaneous  emphvsema  in  enteric 
fever.  99' 
during  measles,  359 
Sudamina  in  enteric  fever,  177 
Sudden  death  in  enteric  fever,  194 
Sudoral  typhoid  fever,   48 
Suppuration,    mastoid,    in    smallpox, 
309 


406 


IXDEX 


Suppuration    of     thyroid     gland     in 

enteric  lever,  202 
Suppurative   pvlephlebitis   in   enteric 

lever,  221 
Surgical  scarlet  lever,  344 
Sweating  in  enteric  fever,  48,  259 

measles,,  349 
Swelling,  glandular,  in  enteric  fever, 

124,  223 
Sj-novitis  in  chicken  pox.  379 
in  enteric  fever,  177,  2(j5 
in  German  measles,  3S9 


Temperature  during  enteric  fever,  44, 
(38,  205 
variations  from  usual  in  onset,  44 
Temporosphenoidal  abscess  in  scarlet 

fe\er,   322 
Testicle  in  enteric  fever,  205 
Tetany  in  enteric  fe\-er,  251 

in  scarlet  fever,  340 
Thorax  and  abdomen,  oedema  of,  after 

enteric  fever,  262 
Throat     complications     in     German 

measles,  385 
Thrombosis    of    cerebral    sinuses    in 
smallpox,  309,  315 
and  embolism,  cerebral,  in  enteric 

fever,  170 
in  enteric  fever,  170,  195,  203 
in  measles,  365 
Thyroid  glantl  in  enteric  fever,  262 
in  German  measles,  385 
in  smallpox,  311 
suppuration    of,    in    enteric 
fever,  262 
Thyroiditis  in  chickenpox,  378 
Tongue  in  smallpox,  310 
Tonsillitis  in  scarlet  fever,  332 
Tonsils  in  enteric  fever,  57 

in. measles,  356 
Tremors  in  enteric  fever,  245 
Tuberculosis  during  enteric  fever,  104, 
191,  270 
of  lungs  following  measles,  353, 

371 
miliarv,  resembling  enteric  fever, 

270,"  271 
of  skin  in  measles,  358 
Tuberculous     peritonitis     resembling 

enteric  fever,  271 
Typhoid  cholangitis  in  enteric  fever, 
218 
coxitis  in  enteric  fever,  264 


Typhoid  fe\er  or  enteric  fe\er,  17 

"sudoral,"  in  enteric  fever,  48 
spine  in  enteric  fever,  246 
Typhus  levissimus  or  short  duration 
enteric  fever,  78 


U 


Ulcer,  corneal,  in  measles,  365 
gastric,  in  enteric  fever,  126 
intestinal,  in  enteric  fever,  128 
of  ^•ul\•a  in  measles,  3(53 
Ulceration,  corneal,  in  smallpox,  307 
of  larynx  in  smallpox,  309 
of  palate  in  smallpox,  310 
Ulcerative     endocarditis     resembling 
enteric  lexer,  270 
in  smallpox,  311 
laryngitis  in  measles,  350 
stomatitis  in  enteric  fever,  212 
in  measles,  354 
in  smallpox,  310 
Unpmia  in  scarlet  fever,  .327 
Urethritis  during  enteric  fe\-er,  206 

measles,  302 
Urinary  casts  in  enteric  fever,  56,  116 
in  measles,  361 
in  smaU]TOx,  313 
Urine,  casts  in,  during  enteric  fe^er, 
116 
pus  in,  during  enteric  fever,  119 
retention  of,  in  chickenpox,  379 
in  enteric  iexer,  57 
in  smallpox,  312 
Urticaria  in  measles,  358 
in  scarlet  fever,  318 


"\'aricella  or  chickenpox,  373 
^'ariola,  301 

Vascular  lesions  in  enteric  fever,  199 
"N'eins  in  enteric  fever,  201 
"\'esicles,  miliary,  in  measles,  359 
"N'omiting  in  chickenpox,  373 
in  enteric  fever,  59,  125 
in  German  measles,  386 
in  scarlet  fever,  334 
Vulva,  ulcers  of,  in  measles,  363 
"N'ulvitis  during  measles,  363 


W 


Water    supply    as   cause    of   enteric 
fever,  19 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

WfiR    *'   A    194j 

1 

1 

Pl"8l949 

C28(23S)M100 

lvCl&7 


H22 
1909 


Kare 


Thp.  medical   complications    •••   of 


